Flank pain resident survival guide

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Flank pain
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Qasim Khurshid, M.B.B.S.

Synonyms and Keywords: Flank pain work-up, Approach to flank pain, Flank pain management

Overview

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.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.[1][2] Listed below are the life threatening causes:

Common Causes

Common causes of flank pian include:[3][1][2]

Diagnosis

Shown below is an algorithm summarizing the diagnosis of flank pain.[4]

 
 
 
 
 
 
 
 
 
Patient History
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pyuria
 
 
 
 
 
Hematuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider uninary tract infection or pyelonephritis
 
 
 
 
 
Consider nephrolithiasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Spiral CT scan of abdomen
 

Treatment

Shown below is an algorithm summarizing the treatment of flank pain.[5][6][7]

 
 
 
 
 
 
 
 
Acute Flank Pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History
Physical exam
Laboratory evaluation
non contrast CT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stone is not identified
 
 
 
 
 
 
 
 
 
 
 
 
 
Stone identified
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternate diagnois
1.Non-urologic
2.Alternate GU diagnosis
 
 
 
 
 
 
 
 
 
 
 
Obstruction present
 
 
 
Obstruction absent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Any of the following signs present?
Fever
Solitary Kidney
UTI
WBC>15K
Rising Serum Creatinine
Bilateral obstruction
Signs of sepsis
 
 
 
Solitary kidney or uncontrolled symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inpatient management
Prompt surgical drainage(stent vs nephrostomy tube)
Consider antibiotics and urine culture
 
 
 
Out patient management
Oral anagescis
Alpha blockers<Repeat imaging as vindicated
 
 
 
Inpatient management
Analgescis (IV or oral)
Alpha blockers
Consider surgical drainage for solitary kidney
 
 

Do's

Don'ts

References

  1. 1.0 1.1 Rippel, Christopher; Raman, Jay D. (2013). "Acute Flank Pain": 19–27. doi:10.1007/978-3-642-28732-9_3.
  2. 2.0 2.1 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.
  3. 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.
  4. 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.
  5. Manjunath A, Skinner R, Probert J (February 2013). "Assessment and management of renal colic". BMJ. 346: f985. doi:10.1136/bmj.f985. PMID 23430331.
  6. 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.
  7. 7.0 7.1 7.2 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.