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Principle of management of rt flank pain

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Management of Right flank pain

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Principle of management of rt flank pain

  1. 1. Principle of Management of Right flank pain in a Man by Dr Badmus A. M
  2. 2. Outline • Introduction/Definition • Anatomy • Causes of right flank pain • Management history taking Examination Investigation Definitive management • Conclusion
  3. 3. Introduction Flank pain is a common complaints in Urology outpatient clinics and emergencies. Conditions from other specialty can also present with flank pain. Its usually unilateral but can also be bilateral. It results from the stimulation of specific nerve endings upon stretching of the renal capsule or vessels.
  4. 4. Anatomy
  5. 5. Causes of Right flank pain • Ureteric calculi • Pyelonephritis • Renal abscess • Renal tumor • Nephrolithiasis • Renal papillary necrosis • Ureteric blood clot • Muscle pain • Acute renal infarction
  6. 6. • Radiculitis • Muscle pain • Appendicitis • Gastrointestinal diseases eg pancreatitis • Adrenal tumors • Gall bladder disease • Liver disease
  7. 7. Management • Adequate history taking, characterising the flank pain, associated symptoms. • Examination should be thorough to rule out possible causes of flank pain and not just limiting to Urology causes alone
  8. 8. Investigation • urinalysis+mcs • plain abdominal xray • Abdominal ultrasound scan • Abdominal CT scan • IVP • Serum uric acid • Lumbosacral xray
  9. 9. Plain abdominal X-ray
  10. 10. CT scan
  11. 11. Ureteral Calculi • Classic presenting symptoms is flank pain. • Prominent cause of flank pain in the absence of fever • Might radiates to the groin, anterior abdomen,testicle • Microscopic or gross hematuria • Nausea and vomiting
  12. 12. Pyelonephritis • Common cause of flank pain • Relatively described as dull ache pain • Associated fever, chills ,nausea and vomiting. • Flank and costovertebral angle tenderness are present. • Patient tend to be very still when compared to patient with renal colic
  13. 13. Abdominal Aortic Aneurysm(AAA) • Present with flank pain, mimicking renal colic. • Occurs in 10% of patients initially being investigated for renal cause. • Aneurysm caused by injury or stretching of nerve plexus around celiac axis. • The aneurysm can lie adjacent to the ureter
  14. 14. Renal abscess • More intense pain than pyelonephritis • There might be flank mass palpable • Fever and chills are common. • Diaphragmatic irritation may cause rales and decreased breath sound on the affected side. • Diabetes mellitus is a risk factor
  15. 15. • Consider renal abscess in a patient with pyelonephritis, not improving with antibiotics therapy. There are of two types: • Corticomedullary type Ascending UTI, Urinary tract abnormality, E.coli most common • Cortical type hematogenous spread,S.aureus
  16. 16. Blood clots • Cause acute renal colic attack when they form ureteral obstruction. • Can be iatrogenic such as percutaneous renal biopsy • Underlying medical pathology such as blood dyscrasias, renal pelvis or parenchymal tumors, angiomyolipomas, hemophilia, sickle cell disease, glomerulonephritis
  17. 17. Papillary Necrosis • Can cause acute ureteral obstruction from the sloughed papilla. • The ring sign in the renal calyx on IVP is characteristic of this disorder. • Women more affected than men • Underlying pathologies: Analgesic abuse, liver cirrhosis, recurrent pyelonephritis, tuberculosis, Sickle cell disease, systemic vasculitis
  18. 18. Renal Tumors • Renal tumor causes flank pain directly or indirectly. • Renal tumor cause renal capsular stretching and pain as well as hematuria with possible ureteral obstruction from the blood clot
  19. 19. UreteroPelvic Junction (UPJ) Obstruction • UPJ obstruction is one of the more common cause of renal pain. • Usually an incidental finding • Pain usually follows ingestion of large amount of fluid, causing a brisk diuresis resulting in renal pelvis distension. • Diagnosis confirmed by a diuretic-enhanced renal nuclear scan
  20. 20. Retroperitoneal fibrosis • Idiopathic disease. • When it involves the ureters, it causes ureteral midline deviation, hydronephrosis and even renal failure. • Pain usually located in lower flank, but abdominal, testicular or periumbilical pain develops later.
  21. 21. Ureteral strictures • Resulting from trauma, surgical intervention, radiation, stone passage, infection. • Commonly affect UPJ,ureterovesical junction and overlying the bifurcation of the iliac vessels.
  22. 22. Acute renal infarction • Affect both kidneys and sexes equally. • Risk factors include age > 50yrs,patient with increased risk of thromboembolism e.g chronic atrial fibrillation with inadequate anticoagulation • Usually unilateral flank pain and hematuria
  23. 23. Other causes • Muscle pain: arising from strain or other injury of the back or flank • Dull aching pain. • Herpes zoster: moderately severe burning pain around the flank corresponding to a dermatone
  24. 24. • Radiculitis: When a lumbar or lower thoracic nerve root are injured • When the pain affects the 10th ,11th or 12th rib, the discomfort mimic renal colics. • Fungal bezoars: Most commonly are candida or Aspergiluus. • Usually in immunocomprosed men
  25. 25. Treatment Renal abscess • Drainage of the abscess either by open surgery or percutaneous methods. •Culture specific antibiotics •Analgesic Blood clots Ureteral stent or percutaneous nephrostomy
  26. 26. Pyelonephritis • Culture specific antibiotics • Analgesic Renal tumors • Optimise patient • Radical nephrectomy
  27. 27. Retroperitoneal fibrosis • Analgesic • Ureterolysis Papillary Necrosis •Resuscitation •Treatment of the underlying pathology •Bypassing the obstruction with a nephrostomy or stent
  28. 28. Ureteral calculi •Analgesic •Liberal fluid intake/IV hydration •Antiemetics •Antibiotics •Alkalinizing agents(e,g potassium citrate,sodium bicarbonate) for uric acid and cysteine calculi •Calcium channel blocker (e.g nifedipine) •Alpha blockers (e.g tamsulosin)
  29. 29. Stones that are 7mm and more are unlikely to pass spontaneously and require some forms of surgical procedure. •Stent placement •Percutaneous nephrostomy •Extracorporeal shockwave lithotripsy •Ureteroscopy •Percutaneous nephrostolithotomy •Open nephrostomy
  30. 30. Conclusion A patient presenting with flank pain should be thoroughly clerked, examined and appropriately investigated because there are several causes of flank pain aside urinary calculi
  31. 31. Thank you for listening