A 63 year-old male with a history of hypertension, tobacco use, and nephrolithiasis presents with left-sided flank pain. He notes sudden-onset approximately 4 hours prior to presentation and describes radiation to his groin. Pain was associated with nausea, denies hematuria and states pain is different compared to prior kidney stones. On evaluation, vital signs are notable for tachycardia (114bpm), blood pressure measured at 112/65mmHg. The patient appears uncomfortable and examination is notable for a pulsatile abdominal mass above the umbilicus.

ED Course

Normal

Abdominal Aortic Aneurysm

A point-of-care ultrasound is performed which shows no hydronephrosis and an 8cm infrarenal abdominal aortic aneurysm. Vascular surgery was consulted and a CTA was performed revealing ruptured abdominal aortic aneurysm. Uncrossmatched blood products were administered en route to the operating room due to hypotension.

Algorithm for the Evaluation of Flank Pain with Ultrasound

Gallery

The POCUS Atlas
The ultrasound images and videos used in this post come from The POCUS Atlas, a collaborative collection focusing on rare, exotic and perfectly captured ultrasound images.

• Aorta
• Lung
• Renal
• Gallbladder

Normal

Abdominal Aortic Aneurysm

Abdominal Aortic Aneurysm

Dissection Flap

  View Gallery

Normal

Subpleural Consolidation

Pleural Effusion

Pneumothorax

  View Gallery   View Algorithm

Normal

Mild Hydronephrosis

Moderate Hydronephrosis

Severe Hydronephrosis

  View Gallery

Gallstones

Many gallstones

Gallbladder wall thickening

Pericholecystic fluid

Choledocholithiasis

Common bile duct dilation

  View Gallery   View Algorithm

References

1. Moore CL, Daniels B, Singh D, Luty S, Molinaro A. Prevalence and clinical importance of alternative causes of symptoms using a renal colic computed tomography protocol in patients with flank or back pain and absence of pyuria. Acad Emerg Med. 2013;20(5):470-478.
2. ​​Prince L.A., & Johnson G.A. (2020). Aneurysmal disease. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.),Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.
3. Bueschen AJ. Flank Pain. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 182. Available from: https://www.ncbi.nlm.nih.gov/books/NBK292/
4. Carter MR, Green BR. Renal calculi: emergency department diagnosis and treatment. Emerg Med Pract. 2011;13(7):1-17;
5. https://wikem.org/wiki/Abdominal_aortic_aneurysm

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A 45 year-old female with a history of ureterolithiasis s/p bilateral percutaneous nephrostomies, hypertension and diabetes presents to the emergency department with flank pain and dysuria for two days. She noted that output from her right nephrostomy had diminished. On evaluation, her vital signs are notable for fever and tachycardia but are otherwise normal. Examination demonstrates right costovertebral angle tenderness to percussion. Drain sites appeared normal, without overlying erythema. Urinalyses from both nephrostomy collection bags were submitted. Computed tomography of the abdomen and pelvis was obtained to evaluate for nephrostomy malposition.

Hospital Course

The patient was treated with parenteral antibiotics based on prior culture data and was admitted to the intensive care unit with urology consultation and plan for interventional radiology percutaneous drainage. The patient underwent uncomplicated perinephric drain placement and nephrostomy exchange and was discharged on hospital day five to complete a course of oral antibiotics.

An Algorithm for the Evaluation and Management of Emphysematous Urinary Tract Infections

References

1. Evanoff GV, Thompson CS, Foley R, Weinman EJ. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med. 1987;83(1):149-154.
2. Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology. 1996;198(2):433-438. doi:10.1148/radiology.198.2.8596845.
3. Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology. 1997;49(3):343-346. doi:10.1016/S0090-4295(96)00501-8.
4. Chen MT, Huang CN, Chou YH, Huang CH, Chiang CP, Liu GC. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. JURO. 1997;157(5):1569-1573.
5. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000;160(6):797-805.
6. Roy C, Pfleger DD, Tuchmann CM, Lang HH, Saussine CC, Jacqmin D. Emphysematous pyelitis: findings in five patients. Radiology. 2001;218(3):647-650. doi:10.1148/radiology.218.3.r01fe14647.
7. Park BS, Lee S-J, Kim YW, Huh JS, Kim JI, Chang S-G. Outcome of nephrectomy and kidney-preserving procedures for the treatment of emphysematous pyelonephritis. Scand J Urol Nephrol. 2006;40(4):332-338. doi:10.1080/00365590600794902.
8. Grupper M, Kravtsov A, Potasman I. Emphysematous cystitis: illustrative case report and review of the literature. Medicine (Baltimore). 2007;86(1):47-53. doi:10.1097/MD.0b013e3180307c3a.
9. Mokabberi R, Ravakhah K. Emphysematous urinary tract infections: diagnosis, treatment and survival (case review series). Am J Med Sci. 2007;333(2):111-116.
10. Yao J, Gutierrez OM, Reiser J. Emphysematous pyelonephritis. Kidney Int. 2007;71(5):462-465. doi:10.1038/sj.ki.5002001.
11. Thomas AA, Lane BR, Thomas AZ, Remer EM, Campbell SC, Shoskes DA. Emphysematous cystitis: a review of 135 cases. BJU Int. 2007;100(1):17-20. doi:10.1111/j.1464-410X.2007.06930.x.
12. Falagas ME, Alexiou VG, Giannopoulou KP, Siempos II. Risk factors for mortality in patients with emphysematous pyelonephritis: a meta-analysis. JURO. 2007;178(3 Pt 1):880–5–quiz1129. doi:10.1016/j.juro.2007.05.017.
13. Somani BK, Nabi G, Thorpe P, et al. Is percutaneous drainage the new gold standard in the management of emphysematous pyelonephritis? Evidence from a systematic review. J Urol. 2008;179(5):1844-1849. doi:10.1016/j.juro.2008.01.019.
14. Aswathaman K, Gopalakrishnan G, Gnanaraj L, Chacko NK, Kekre NS, Devasia A. Emphysematous pyelonephritis: outcome of conservative management. Urology. 2008;71(6):1007-1009. doi:10.1016/j.urology.2007.12.095.
15. Kapoor R, Muruganandham K, Gulia AK, et al. Predictive factors for mortality and need for nephrectomy in patients with emphysematous pyelonephritis. BJU Int. 2010;105(7):986-989. doi:10.1111/j.1464-410X.2009.08930.x.
16. Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int. 2011;107(9):1474-1478. doi:10.1111/j.1464-410X.2010.09660.x.
17. Lu Y-C, Chiang B-J, Pong Y-H, et al. Predictors of failure of conservative treatment among patients with emphysematous pyelonephritis. BMC Infect Dis. 2014;14(1):418. doi:10.1186/1471-2334-14-418.

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Key Historical Findings

Onset

Acute onset with associated activity suggests mechanical process

Acute onset without trigger, particularly if severe pain may suggest vascular process

Progressive onset without trigger suggests non-mechanical process (i.e. malignancy)

Aggravating/Alleviating Factors

Worsening with cough/valsalva suggests herniated disk

Relief with flexion associated with spinal stenosis

Location/Radiation

Radicular pain typically extends below knee, associated with nerve root involvement

Radiation to/from chest or abdomen suggests visceral source

Flank location suggests retroperitoneal source

History/Associated Symptoms

Fever

Medications (particularly anti-coagulants)

Hematuria

Malignancy

IVDA

Vascular disease

Key Physical Findings

• Abnormal vital signs
  • Fever: abscess, osteomyelitis, discitis
  • Hypertension: dissection
  • Shock: AAA
• Localize point of greatest tenderness
• Examine abdomen for pulsatile mass
• Perform thorough neurological examination including rectal tone and perianal sensation
• Positive straight leg raise associated with sciatic nerve root irritation and is sensitive (but not specific) for disk disease.

References

1. Mahoney, B. (2013). Back Pain. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 278-284). Elsevier Health Sciences.
2. WikEM: Lower back pain

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