Right flank pain, did i miss something?

[prolene60]

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Had a 60 yo guy with several days of atraumatic right flank pain much worse today along with n/v. While I'm talking to him(he's lying on the stretcher) he sharply winces q minute or so. His abdomen is completely normal, has some right CVA Tenderness. vitals are stable, Lungs are clear and he denies any chest pains. Pain gets worse when he lies on his right side or swings his right leg over. But again he suddenly winces just every couple minutes while lying still. CT non-con shows a 4.5mm calculus on the right still in the kidney, no where in the ureter, no hydro, urine shows no infxn, no blood. Left kidney completely clear. The guy is obviously feeling much better after the pain meds and anti-emetics. Ended up referring him to urology outpt and called him nephrolithiasis. But looking back on it, I'm a little unsure because generally non-ureteral stones don't usually cause pain. I know you can also still have stones with no blood in the urine in 15-20% cases but still. I'm hoping I didn't miss a dissection or a renal infarct or something.

 

[ILEMres]

Im assuming you did a non contrast ct. Do you remember what his blood pressure was? Roughly? I would have done a contrasted study on him. Dont worry though, you did an appropriate work up.

 

[Janders]

While your patient's pain does sound like renal colic, I hate to ascribe pain to a stone that is hanging out inside the kidney (i.e. not engaged in the ureter), though one supposes it could ball-valve occasionally... still that 4.5mm stone has been growing for sometime, why would it suddenly hurt today unless it has started to migrate down?

Can't tell you what precisely is wrong with your patient, of course. I can tell you what I've found in patients I initially THOUGHT had renal colic: Diverticulitits (way up in the flexure), renal infarct (afib), pyelo(afebrile), acute chole (GB tucked way behind liver), RP bleed (more than once... once from renal capsular bleed, some spontaneous), renal artery dissection (there but the grace of god), PE a few times (pleuritic component, or explained tachycardia were the hints), pneumonia (seen on CT), renal cell carcinoma bleeding into itself (thank you CT scanner), spleenic infart (2x, no cause found), compression frx of spine with radiculopathy...

 

[ThoracicGuy]

Had a 60 yo guy with several days of atraumatic right flank pain much worse today along with n/v. While I'm talking to him(he's lying on the stretcher) he sharply winces q minute or so. His abdomen is completely normal, has some right CVA Tenderness. vitals are stable, Lungs are clear and he denies any chest pains. Pain gets worse when he lies on his right side or swings his right leg over. But again he suddenly winces just every couple minutes while lying still. CT non-con shows a 4.5mm calculus on the right still in the kidney, no where in the ureter, no hydro, urine shows no infxn, no blood. Left kidney completely clear. The guy is obviously feeling much better after the pain meds and anti-emetics. Ended up referring him to urology outpt and called him nephrolithiasis. But looking back on it, I'm a little unsure because generally non-ureteral stones don't usually cause pain. I know you can also still have stones with no blood in the urine in 15-20% cases but still. I'm hoping I didn't miss a dissection or a renal infarct or something.

Just remember, you can have a retrocecal appendix that can sometimes fool you.

 

[Khaos]

The good news is it sounds like you did an appropriate work up for flank pain. Most non-con CT scans will find appendicitis for you. Heck, you can see diverticulitis, significant gallbladder disease, and most other inflammatory processes on a non-con. Now, even with a contrasted study you are going to miss dissection, mesenteric infarct, and small retroperitoneal bleeds. So, unless you plan to do CT angio of abdomen on all patients that present with flank pain or abdominal pain without risk factors, you are going to miss the rare things. You are always going to find a doc that once found something. You have to know the risks for these things and test appropriate.

 

[bougiecric]

Im assuming you did a non contrast ct. Do you remember what his blood pressure was? Roughly? I would have done a contrasted study on him. Dont worry though, you did an appropriate work up.

Why does the blood pressure matter, and why would you have done a contrasted CT?

 

[Groove]

If your clinical gestalt does not jive with your lack of diagnostic certainty, then continue to look elsewhere. I can't tell very much without more info about your work up but from what you've described, I'd have no problem spinning him up again with contrast and don't forget mesenteric ischemia on your ddx (can present very atypically...) You might even think about starting the contrasted study with CT angio and chat with radiology before hand to optimize the delay phase to get a better "all around" second pass contrasted study.

 

[ILEMres]

Why does the blood pressure matter, and why would you have done a contrasted CT?

I would be looking for vascular pathology, renal infarct & mesenteric ischemia. W the BP, I'd vary my approach if it was either high or low. Low BP, be more concerned w intra-abd sepsis/ischemic gut, w high bp I'd be more concerned w aortic dissection/renal vascular disease.

 

[bougiecric]

I would be looking for vascular pathology, renal infarct & mesenteric ischemia. W the BP, I'd vary my approach if it was either high or low. Low BP, be more concerned w intra-abd sepsis/ischemic gut, w high bp I'd be more concerned w aortic dissection/renal vascular disease.

Continuing to play devil's advocate... let me summarize the case:

60 yo man
Right flank pain and n/v -- resolved with symptomatic treatment
Non-diagnostic non-contrast CT

I'd say this isn't an uncommon presentation. Do you CTA them all? It sounds like you make somewhat of a distinction based on BP: you'd CTA if it's high or low. If it's normal, no CTA? I personally don't see BP being particularly helpful in this scenario. If the BP was low, he obviously wouldn't have discharged the patient. If it was high... so is everybody else's in the ED.

I agree with Groove in that if your gestalt tells you something's wrong, or they look sick, or there are other red flags, then certainly proceed to look further. However, in the synopsis given, I didn't catch any obvious red flags.

I'd also argue that the most likely catastrophic vascular pathology with this presentation would be a AAA, which is easily screened for on a non-contrast CT. The main thing I worry about missing by not doing a CTA is mesenteric ischemia, which would be quite atypical for this presentation, and which lactate has a decent sensitivity for.

 

[ILEMres]

Angio everyone? No. But elderly w flank/abd pain, I try to get contrasted studies. And yes, the BP & HR play a major role in my decision making.

 

[EM4life]

I think I probably would have CTA'd this guy based on his pain and lack of evidence of a kidney stone in transit and age. But what do you guys do if this guy has some underlying renal insufficiency like many his age? I feel like this happens fairly often.