Flank pain resident survival guide
Resident Survival Guide
Synonyms and Keywords: Flank pain work-up, Approach to flank pain, Flank pain management
Flank pain refers to the discomfort in the upper abdomen or back and sides. It develops in the area above the pelvis and below the ribs. This is a common symptom and usually, pain is worse on one side of the body. Most frequently, the cause is benign and/or self-limiting, but more serious causes may require urgent intervention. Treatment of the flank pain depends on the cause, urgent surgical intervention may be required if the pain is caused by ruptured aortic aneurysm and some conditions can be treated with NSAIDS.
Life Threatening Causes
- Ruptured Abdominal Aortic Aneurysm
- Renal abscess
- Perforated gastric ulcer
- Renal artery dissection
- Traumatic splenic rupture
- Acute pancreatitis
- Adrenal hemorrhage
- Pulmonary embolism
- Abdominal muscle strain
- Acute kidney injury
- Ureteric calculi
- Renal abscess
- Renal tumor
- Post streptococcal glomerulonephritis
- Renal papillary necrosis
- Ureteric blood clot
- Acute renal infarction
Shown below is an algorithm summarizing the diagnosis of flank pain.
|Pulmonary Symptoms||Urinary Symptoms||colic|
|Considor PE or pneumonia||Consider UTI or nephrolithiasis||Consider hepatobiliary cause or nephrolithiasis|
|Physical Examination||Physical examination||Physical Examination|
|Tachypnea,hypoxia or pulmonary findings||Costovertebral or suprapubic tenderness||Perform ultrasonography of abdomen,if non diagnostic consider nephrolithiasis|
|Chest radiography,if non diagnostic, helical CT or D dimer to evaluate for pulmonary embolism||Perform Urinalysis|
|Consider uninary tract infection or pyelonephritis||Consider nephrolithiasis|
|Spiral CT scan of abdomen|
|Acute Flank Pain|
non contrast CT
|Stone is not identified||Stone identified|
|Consider alternate diagnois|
2.Alternate GU diagnosis
|Obstruction present||Obstruction absent|
|Any of the following signs present?|
Rising Serum Creatinine
Signs of sepsis
|Solitary kidney or uncontrolled symptoms|
Prompt surgical drainage(stent vs nephrostomy tube)
Consider antibiotics and urine culture
|Out patient management|
Alpha blockers<Repeat imaging as vindicated
Analgescis (IV or oral)
Consider surgical drainage for solitary kidney
- The symptomatic patients of the abdominal aortic aneurysm with hemodynamic stability should be evaluated with abdominal CT as an initial diagnostic test. Abdominal CT provides additional details such as aruptured aneurysm, infected aneurysm, and anatomical details that are important for subsequent management.
- Urgent urologic consultation is warranted in patients with urosepsis, acute kidney injury, anuria, and/or unyielding pain, nausea, or vomiting.
- Patients with stones larger than 10 mm in diameter, patients with significant discomfort, those with significant obstruction, or who have not passed the stone after four to six weeks, should be referred to urology for potential intervention.
- Patients should be advised to strain their urine for several days and bring in stone that passes for analysis. This will help the physician to take effective measures for preventive therapy.
- The patients of APDKD with new-onset flank pain should be suspected for cyst hemorrhage or infection or nephrolithiasis.
- Do not fail to evaluate elder patients in the presence of overt clinical signs.
- Do not delay treatment with antibiotics for pyelonephritis while waiting for blood cultures.
- Do not delay the intervention for life-threatening conditions of flank pain.
- Do not delay resuscitation or surgical consultation for the ill patient while waiting for imaging.
- Rippel, Christopher; Raman, Jay D. (2013). "Acute Flank Pain": 19–27. doi:10.1007/978-3-642-28732-9_3.
- Jha P, Bentley B, Behr S, Yee J, Zagoria R (2017). "Imaging of flank pain: readdressing state-of-the-art". Emerg Radiol. 24 (1): 81–86. doi:10.1007/s10140-016-1443-9. PMID 27614885.
- Evan AP, Worcester EM, Coe FL, Williams J, Lingeman JE (January 2015). "Mechanisms of human kidney stone formation". Urolithiasis. 43 Suppl 1: 19–32. doi:10.1007/s00240-014-0701-0. PMC 4285570. PMID 25108546.
- Taourel P, Thuret R, Hoquet MD, Doyon FC, Merigeaud S, Delabrousse E (2008). "Computed tomography in the nontraumatic renal causes of acute flank pain". Semin Ultrasound CT MR. 29 (5): 341–52. doi:10.1053/j.sult.2008.06.010. PMID 18853840.
- Manjunath A, Skinner R, Probert J (February 2013). "Assessment and management of renal colic". BMJ. 346: f985. doi:10.1136/bmj.f985. PMID 23430331.
- Singh P, Enders FT, Vaughan LE, Bergstralh EJ, Knoedler JJ, Krambeck AE, Lieske JC, Rule AD (October 2015). "Stone Composition Among First-Time Symptomatic Kidney Stone Formers in the Community". Mayo Clin. Proc. 90 (10): 1356–65. doi:10.1016/j.mayocp.2015.07.016. PMC 4593754. PMID 26349951.
- Teichman JM (February 2004). "Clinical practice. Acute renal colic from ureteral calculus". N. Engl. J. Med. 350 (7): 684–93. doi:10.1056/NEJMcp030813. PMID 14960744.