differential diagnosis of flank pain
TRANSCRIPT
DIFFERENTIAL DIAGNOSIS OF FLANK PAIN
Causes of flank pain
1)RENAL CAUSES:-• Urinary tract infection• Hydronephrosis due to renal or ureteric
stones,CA• Acute or chronic pyelonephritis• Other Renal infections a)pyonephrosis• b)renal/perinephric abcess c)renal tuberculosis
• Polycystic kidneys
• Renal/ureteric trauma
• Renal cell CA
• Adrenal tumor or hemorrhage
2)Gynecological/Obstetric causes:-
• Ovarian cyst
• salpingitis
• Ovarian CA
• Ectopic pregnancy
• PID
3)Gastrointestinal causes
• May include
• Diverticulitis
• Tumor arising from ascending or descending colon
• Inflammatory bowel disease
4)Other causes• Referred pain from other sites:- e.g from
back(arithritis or degenerative diseases of disk),pancreatitis.
• Fracture of any of 9th-12th ribs• Muscle spasm• Appendicitis in pregnancy• Drugs e.g:ascorbic acid• Heavy metal poisoning
Evaluation of the patient with flank pain
• History:-1)Age of patient:-2)Pain:-a)Siteb)Onsetc)durationc)Severityd)Relationship with micturitione)Radiationf)Aggravating and relieving factors
3)Urinary complaints:-
a)Burning micturition
b)Dysuria
c)Oliguria
d)polyuria
e)Hematuria
f)Increased frequency of micturition
4)Menstrual and Obstetric history:-a)LMPb)Any history of
dusmenorrhea,oligomenorrhea,polymennorhagea,vaginal discharge.
5)Gastrointestinal complaints:-History of nausea,vomitting,abdominal pain
and altered bowel habits.6)Trauma
Clinical Examination
• General Physical Examination:-• Pallor• Jaundice• Blood pressure• Temperature• Weight loss• Lymph node enlargement• Peripheral edema
• Local Examination• Inspection:-• Swelling or distension,previous scar marks• Colour of overlying skin• Palpation:-• Tenderness• Swelling• Temperature of overlying skin• Palpable kidneys
• Percussion:-
• Aucultation:-
• Renal bruit in renal artery stenosis
Investigations1)Hematological:-a)Blood complete examination• Hb• ESR• TLC • RBC count• b)Renal function tests:-• Blood urea• Serum creatinineC)serum Calcium
d)Serum PTH levels
e)Blood culture and sensitivity
2)Urinary Examination:-a)Volume of urineb)Gross appearance:-for dark colour,hematuria or
cloudy apperanacec)Microscopic examination:-for
hematuria,RBCs,WBCs,Casts,pus cells and crysrals.
d)pH(normal pH 6)e)Specific gravity (Normal 1.002 to 1.025)f)Urine culture and sensitivity
3)Radiological Investigations:-
a)Plain X-ray abdomen
b)Ultrasound abdomen and pelvis:- for renal size,hydronephrosis,renal mass,polycystic kidney,ovarian or tubal abnormalities,ectopic pregnancy
c)Intravenous urogram(IVU)
d)Chest X-ray
Special Investigations
4)Radionuclide studies:-
a)Tc99m-DTPA scan:-
helps to determine the anatomy of kidney and site of obstruction
b)Tc99m-DMSA scan:-• Determines contribution of each kidney in overall
renal functions.
5)CT scan:-
Useful in diagnosis of renal tumors and metastasis
6)MRI:- helps in differentiatian between solid n cystic renal masses.
7)Angiography and venography
8)Antegrade and retrograde urography
9)Micturating cystourography
10)Renal biopsy
Urinary Tract Infection
• UTI is associated with multiplication of organisms in urinary tract and is defined as presence of more than a hundred thousand organisms per ml in midstream sample of urine.
• Causes:- E.coli,proteus,klebsiella,e.fecalis, staphylosoccus saprophyticus or epidermidis
• Clinical features:-
• c/o flank pain,burning micturion,oliguria,dysuria,unpleasant colour and odour of urine
• Investigations:-
• Urine culture and sensitivity
• Urine microscopy
• Treatment:-
• Ciprofloxacin 500mg 12 hourly for 5 to 7 days
• Paracetamol for fever
• Potassium citrate(citralka) for dysuria.
Renal or ureteric calculi• Clinical features:-• Flank pain,dull and deep seated,aggravated
upon walking in case of renal calculi.• Severe exacerbations of pain in ureteric
calculi,pain may radiate to groin,perineum,as the stone progresses down the ureter.
• Hematuria• Uremic symptoms• Tenderness in renal angle,increased pulse
rate,percussion over kidney produces sharp stab pain
• Investigations:-
• KUB:-reveals radio opaque shadows
• Excretory urography
• Ultrasonography
• ureteric catheterization
• Cystoscopy
• Retrograde ureterography
• Treatment• Conservative treatment• Bed rest• Application of warmth at site of pain• Opiod analgesics• Antispasmodics • High fluid intake upto 2 L/day• A suitable antibiotic:-e.g sulfonamide
• Surgical treatment of renal stones:-• Pyelolithotomy• Extended pyelolithotomy• Nephrolithotomy• Partial nephrectomy• Nephrectomy• Percutaneous nephrolithotomy• Extracorporeal shock wave lithotripsy(ESWL)
• Surgical treatment of ureteric calculi:-• Endoscopic removal of stones:- Dormia basket• ureteric meatotomy• extraction through ureteroscope• Lithotripsy in situ• Ureterolithotomy
Acute or chronic pyelonephritis
• Clinical features• Flank pain,dysuria and increased
frequency of micturition,cloudy urine,fever,tenderness in lumbar region
• Investigations• Blood CP:-leukocytosis• Urine microscopy:-numerous pus cells and
organisms• Urine culture and sensitivity
• For chronic pyelonephritis:-
• IVP
• Renal ultrasound
• Urine culture
• Cystoscopy
• Micturating cystourethrogram
• RFTS
• Treatment:-• Ciprofloxacin 750 mg 12 hourly for 21 days • Ofloxacin may b used• Paracetamol• Potassium citrate• In chronic cases,antibiotic to which organism is
sensitive is given for 3-6 months.• Control hypertension.• Remove if there is any obstruction.
Perinephric abcess
• Clinical features• High swinging pyrexia• Loin tenderness and fullness• Investigations• leukocytosis• No characteristic pus cells or organisms in
urine• Plain abdominal radiograph:obscure psoas
shadow
• Ultrasonography and CT are diagnostic.
• Treatment:-
• Aspiration by large percutaneous needle
• Open drainage
Polycystic kidney disease
• The disease is hereditary and potentially lethal.
• Clinical features
• Irregular upper quadrant mass in abdomen
• flank pain
• Hematuria
• Infection
• Hypertension
• uremia
• Investigations
• Renal ultrasound
• Cytological examination of cyst fluid
• IVU
• Treatment
• Low protein diet
• Symptomatic treatment
• Rovsing’s operation:-surgery to uncap the cysts is rarely indicated
Renal trauma
• May occur due to blow or fall on side or loin or crushing injuries of abdomen e.g road traffic accident.
• Clinical features:-
• Flank pain and bruising
• Hematuria
• Severe delayed hematuria
• Investigations:-• Ultrasound abdomen• IVU/contrast enhanced CT• Treatment a)General measures:-• Blood grouping and cross matching• Bed rest and Opiod analgesics• Hourly monitoring of pulse and B.P• Antibiotics• Every sample of urine passed should be checked for
hematuria
• B)surgical exploration:-• Indicated if there are signs of progressive
blood loss or there is expanding mass in flank.
• Small tears are simply sutured over a hemostatic sponge
• Large single rent:-pass tube nephrostomy and suture renal tissue around it.
• Laceration in one pole:-partial nephrectomy.
• When kidney is completely avulsed from its pedicle:-nephrectomy