Flank pain (oxford clin cases) Flashcards
What are some differentials when someone presents with acute flank pain?
Muscle sprain Ureteric colic Pyelonephritis Testicular torsion Leaking or ruptured AAA
What 3 surgical emergencies do you need to rule out when someone presents with acute flank pain?
Pyelonephritis
Ruptured AAA
Testicular torsion
Where will pain from kidney stones be?
Unilateral and radiating from loin to groin
What will be the character of pain if there is a stone in the kidney vs the ureter?
Kidney= constant Ureter= colicky
How severe is pain for kidney stones?
Extremely severe, comparable to childbirth
What other symptoms should you ask about when someone presents with flank pain and why?
Is there any fever- suggests infection
Is there dehydration- predisposes them to kidney stones
Is there any change in urination- dysuria, frequency, urinary obstruction, heamaturia etc
Is there nausea or vomiting- if yes rules out muscle strain, nerve root causes etc
Cloudy urine?- infection
What should you ask about in pmx in someone with flank pain? Explain why
Have they has previous kidney stones- recurrence is not uncommon
Have they had recurrent UTIs- increases risk of stones
Have they had any kidney operations- if one kidney has been removed obstruction of the remaining ureter is a medical emergency
Do they have polycystic kidney disease- increases risk of stones
Do they have atherosclerotic disease- all increase risk of AAA leak/rupture
What should you look for in the drug hx when someone has flank pain and why?
Are they on any drugs that crystallise the urine?- increases risk of blockage
Are they on diuretics- increases dehydration which increases risk of kidney stones
What should you look for on examination of someone with flank pain and why?
Position- if its ureteric colic they won’t be able to lie still and will writhe, if its peritonitis they will lie completely still
Tenderness- flank tenderness in ureteric colic
Mass- expansile AAA
Temperature- indicates infection eg pyelonephritis
Lower limbs- an easily felt popliteal pulse might indicate AAA
Can an AAA be ruled on via clinical examination?
No, you have to image it too
What does acidic urine suggest?
Urate stones
What does alkaline urine suggest?
Presence of bacteria that produce urease which can cause stones
What do red or white cell casts in the urine suggest?
Red or white cells are coming from the kidney
What do red cell casts in urinalysis indicate?
Glomerular damage
What do white cell casts in urinalysis indicate?
Pyelonpehritis
How commonly are white cell casts found?
Not common at all
What 2 tests can be done on urine? When should they be done
Normal urinalysis (looks for haematuria, pH, WBC etc)- do if you suspect any urine pathology
Urine microscopy, culture and sensitivity (looks at the urine in more detail)- do if you urinalysis is abnormal
What bloods would you do for someone with flank pain? Explain why
FBC- look for raised WCC
CRP/ESR- if raised indicates inflammation
U&Es- assess renal function
Serum calcium, phosphate and urate- should be checked in everyone with stones/suspected stones
What is the first line investigation for suspected AAA?
Contrast CT abdomen
What is the best imaging for stones/ flank pain in general and why?
Non contrast CT KUB- it will clearly show any stones and also allows good visualisation of the AAA
In someone with flank pain, if you suspect pancreatitis what investigation should you request?
Serum amylase and lipase
In someone with flank pain, if you suspect perforated peptic ulcer what investigation should you request?
Erect chest x ray
How are kidney stones managed?
If there is no infection or complications they can be conservatively managed with analgesia, fluid intake and an alpha blocker/CCB (to relax ureters)
If infected, abx and monitoring are required
If the stone is small it may pass by itself so the patient can be sent home and asked to strain their urine and bring it back for analysis, if its large it may need to be removed
How can kidney stones be removed?
Shock wave therapy- the stone is shocked so it breaks into smaller fragments that can be passed
Use a ureterorenoscope- up the urethra to remove, place a stent after as it can cause stricture
When should someone with a kidney stone be admitted?
If there is evidence of urinary tract infection
If there is evidence of renal failure
If there is severe pain after analgesia
If there are bilateral obstructing stones or unilateral obstructing stones in a patient with only one kidney
What should patients with kidney stones be advised to do after discharge?
Increase fluid intake
What patients should undergo further testing if they have kidney stones?
If they have a significant family hx of renal stones
If they had multiple stones when they presented
If they have recurrent stones
How will acute pyelonoehritis present?
Flank pain
Vomiting
Fever
Urinalysis showing hematuria, white cells, nitrates
If all investigations for flank pain come back normal what could you suspect?
Back pain
How can back pain be managed?
NSAIDs- if recommending them to patients advise them not to take them regularly or in combination
Weight loss
Build up strength of core muscles
Back care- ensure the muscles are supported, don’t do strenuous activity or bend down a lot etc
NSAIDs are the first line treatment for kidney stones, but who can they not be given too?
Patients with asthma
Patients with severe heart failure (especially COX-2)
Previous or active peptic ulcers
What 3 locations are kidney stones most likely to cause an obstruction?
Pelvoutreteric junction
Pelvic brim
Vesicoureteric junction
Above what diameter should you operate on an AAA?
When they are above 5.5cm in diameter
What are red flags for back pain?
Unintentional significant weight loss Fever Thoracic spine pain Sphincter problems Under 20 or over 50 Nerve root pain that doesn't resolve (in 6 weeks) Severe morning stiffness
How do NSAIDs, opiates and paracetamol differ in how they combat pain?
NSAIDs= reduce inflammation at sight of pain Opiates= reduce transmission of pain signals to the brain Paracetamol= reduces the brains perception to pain
How should you prescribe painkillers for severe pain and why?
In combination- they are more effective this way as they reduce pain in different ways
Anticipating bouts of pain instead of as reactions to them
