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