Flank Pain

Differential Diagnosis in Primary Care, 4th Edition

Most cases of flank pain are associated with inflammation of the kidney. As is shown in Table 29, however, jumping to that conclusion in any given case may be hazardous.

Flank pain

In addition to the kidney (pyelonephritis and perinephric abscess), inflammation of the skin (herpes zoster), the colon (diverticulitis and colitis), the gallbladder (cholecystitis), and the spine (epidural abscess and Pott disease) may also cause flank pain. The mnemonic VINDICATE also suggests several vascular disorders that are significant causes of flank pain such as aortic aneurysms, embolic nephritis, and mesenteric thrombosis. Neoplasms of the kidney and colon are less likely to produce pain unless they are complicated by infection. However, trauma of the kidney and spine and renal calculi—whether due to hyperparathyroidism, idiopathic etiologies, or hyperuricemia—are important causes. Neoplasms of the spinal cord and tabes dorsalis must also be considered.

TABLE 29. Flank Pain

	V	I	N	D	I	C	A	T	E
	Vascular	Inflammatory	Neoplasm	Degenerative	Intoxication Idiopathic	Congenital Acquired Malformation	Autoimmune	Trauma	Endocrine
*Skin*		Cellulitis Herpes zoster						Contusion Laceration
*Muscle and Fascia*		Trichinosis				Hernia	Dermatomyositis	Contusion
*Colon*	Mesenteric thrombosis	Colitis	Carcinoma			Diverticulitis Appendix	Ulcerative colitis Granulomatous colitis	Contusion Laceration
*Gallbladder*		Cholecystitis Cholangitis	Carcinoma
*Adrenal Gland*									Hemorrhage Infarction Tumor
*Kidney*	Embolism Thrombosis	Pyelonephritis Perinephric abscess	Wilms tumor Hypernephroma		Gout Toxic nephritis Crush syndrome	Obstruction Infection due to malformation	Periarteritis nodosa Vasculitis of other cause	Contusion Laceration	Calculus due to hyperparathyroidism
*Aorta*	Aneurysm			Atheroma Dissecting aneurysm				Rupture
*Vena Cava*	Thrombosis
*Spine*		Osteomyelitis Tuberculosis	Metastatic carcinoma	Osteoarthritis			Marie–Strümpell disease	Fracture Herniated disc
*Spinal Cord and Nerves*	Anterior spinal artery occlusion	Tabes dorsalis Myelitis Epidural abscess	Spinal cord tumor		Arsenic poisoning Porphyria	Syringomyelia	Guillain–Barré syndrome	Hematoma

Approach to the Diagnosis

The diagnosis of flank pain usually involves careful examination of the urine and a urine culture, an IVP, and plain films of the abdomen and spine. If these are negative, bone scans, arteriogram, and other tests listed below may be required. CT has eliminated the need for exploratory laparotomy in many cases.

Other Useful Tests

1. Urology consult

2. Neurology consult

3. CBC

4. Chemistry panel (uremia, renal calculi)

5. CT scan of the abdomen and pelvis (neoplasms, stones, hemorrhage abscess)

6. X-rays of the thoracolumbar spine (bone metastasis, herniated disc)

7. MRI of the thoracic spine (neoplasms, herniated disc)

8. Sonogram (renal cyst)

9. Urine for acid-fast bacillus (AFB) smear and culture (tuberculosis)

10. Cystoscopy and retrograde pyelography (malformations, neoplasm)

11. Protein electrophoresis (multiple myeloma)

Case Presentation #29

A 36-year-old black woman complained of severe left flank pain for 3 days. She denies fever, dysuria, or hematuria.

Question #1. Utilizing the methods discovered above, what would be your list of possibilities at this point?

Physical examination is unremarkable except for hyperesthesia and hyperalgesia in the distribution of T12 dermatome on the left. Urinalysis is negative.

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Question #2. What diagnosis would you consider most likely now?

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