Acute Flank Pain Research Articles

7917 Bilateral Adrenal Hemorrhages As The Initial Presentation Of Poorly Differentiated Bronchogenic Carcinoma

Abstract Disclosure: B. Malapur: None. M.G. Jakoby: None. V. Williams: None. Introduction: Bilateral adrenal hemorrhage is rare, and most cases occur in the setting of bacterial sepsis, coagulopathies such as antiphospholipid antibody syndrome, treatment with anticoagulants, surgery, or trauma. We present a patient with asynchronous bilateral adrenal hemorrhages that resulted in an eventual diagnosis of poorly differentiated bronchogenic carcinoma. Case: A 65-year-old female smoker was found to have a large right adrenal hematoma on computed tomography (CT) obtained for evaluation of acute onset right flank pain. No hemorrhage or anatomic abnormalities of the left adrenal gland were apparent, and the patient was discharged home after her pain was controlled. Approximately one month later, she returned to hospital with bilateral flank pain, and bilateral adrenal hemorrhages were diagnosed on repeat CT imaging. An 8 cm left upper lobe lung mass was revealed on a chest CT scan, and cytology from a bronchoscopic biopsy confirmed poorly differentiated bronchogenic carcinoma. The patient had no recent surgeries, abdominal trauma, or treatment with anticoagulants, serologic evaluation for coagulopathies and disseminated intravascular coagulation was unremarkable, blood cultures failed to grow bacterial pathogens, and acid-fast staining of lung tissue was negative. The patient was discharged from her second hospital admission on hydrocortisone and fludrocortisone. Discussion: Adrenal hemorrhage in the setting of malignancy is usually a complication of adrenal metastases. The prevalence of adrenal metastases in advanced stage cancer is approximately 3%, with lung and breast cancers and melanoma showing the highest predilection for adrenal metastases. This case is unusual because the patient had no focal masses or disruption of left adrenal contour on CT to indicate adrenal metastases at the time of right adrenal hemorrhage, and she did not have other established risk factors for pathologic bleeding in the setting of malignancy such as thrombocytopenia or treatment with chemotherapy agents, anticoagulants, or nonsteroidal anti-inflammatory drugs. Adrenal hemorrhage is also a rare inciting event resulting in the diagnosis of lung cancer; to date, there are only 29 published cases of spontaneous adrenal hemorrhage as the initial presentation of lung cancer. This case illustrates the importance of careful evaluation for malignancy in patients with spontaneous adrenal hemorrhage and no clear etiology for adrenal bleeding. Presentation: 6/1/2024

When flank pain leads to fainting: a case of a ruptured angiomyolipoma diagnosed by point-of-care ultrasound

BackgroundAcute flank pain is a common presentation in the Emergency Department (ED). Point-of-care ultrasound (PoCUS) has emerged as an invaluable tool in the evaluation of acute flank pain and provides real-time images resulting in the early identification of the underlying pathology.Case ReportHere we report a case of a young lady presented to the ED with a complaint of right flank pain followed by a syncopal episode. The diagnosis of ruptured angiomyolipoma was made using a PoCUS and an immediate consult to interventional radiology and urology was provided.ConclusionThis case highlights the importance of PoCUS in assessing patients presented to the ED with acute flank pain. Its incorporation into clinical practice promises to revolutionize the approach to renal emergencies, emphasizing its important role in delivering timely and effective care.

Extensive Left Sided Venous Thrombi and Bilateral Pulmonary Emboli in the Context of May-Thurner Syndrome for a Patient Presenting with Acute Flank Pain: A Case Report

May-Thurner syndrome is an underappreciated differential in the context of deep venous thrombosis. It is a symptomatic congenital abnormality resulting from compression of the left common iliac vein, sometimes also referred to as iliac vein compression syndrome in the literature. This case reports the presentation of a female with acute flank pain to the emergency department following a recent laparotomy for a complicated tubo-ovarian abscess. She was subsequently diagnosed with a sub-acute thrombus extending from the left common femoral vein into the left inferior vena cava, as well as new bilateral pulmonary emboli. As the patient had relative contraindications to thrombolysis, a shared decision was made with the vascular team to opt for conservative management only. In this instance, this included long-term oral anticoagulant therapy and compression stockings. This case asserts that clinicians should maintain a high index of suspicion for May-Thurner syndrome in the context of extensive left-sided thrombus formation.

A comparative study of ultrasonography (USG) and computed tomography for detecting ureteric calculi in patients with acute flank pain, and analysis of factors influencing ultrasound detection rates

Introduction: Urolithiasis, a frequent urologic issue, often relies on computed tomography (CT) scans, the preferred imaging technique. However, in low-income countries like Nepal, access to CT scans is limited. The authors’ study focused on comparing ultrasound (US) and CT for assessing ureteric calculi in patients with acute flank pain and examined factors influencing US detection rates in these patients. Methods: The authors conducted a cross-sectional study using purposive sampling, involving 87 participants who presented with acute flank pain at a tertiary hospital in Nepal. Ethical clearance was obtained from the institutional review board. Results: Among the 87 patients presenting with acute flank pain, the majority were male (51, 58.62%). Of the 78 cases with CT-detected ureteric calculi, the most common locations were distal ureter (23/78, 29.49%), followed by proximal ureter (21/78, 26.92%), and pelvic-ureteric junction (PUJ) (20/78, 25.64%). Ultrasound demonstrated varying sensitivities for detecting ureteric calculi: 95.00% for PUJ, 100.00% for vesicoureteric junction (VUJ), 66.67% for proximal ureter, and 56.52% for distal ureter calculi. The highest sensitivity was observed for calculi greater than 15 mm (100%), followed by 10.1–15 mm (77.7%). Overall, ultrasound exhibited a sensitivity of 76.92%, a specificity of 100%, and an accuracy rate of 79.31% in detecting calculi. Notably, patients with hematuria had significantly higher odds of ultrasound-detected ureteric calculi (odds ratio: 36.68, 4.54–296.26, P<0.01) than those without hematuria. However, age, hydronephrosis, calculi location, and laterality were not found to be significantly associated with ultrasound detection. Conclusions: Due to its good sensitivity, ultrasound can serve as the first-line investigation for individuals experiencing acute flank pain, given its cost-effectiveness and radiation-free nature when compared to CT scans. CT scans should be reserved for patients exhibiting clinical symptoms of severe ureteric colic who have previously undergone a negative ultrasound (USG).

Pelvicalyceal system rupture due to obstruction by lower ureteric calculus

Abstract The most common cause of spontaneous non traumatic pelvicalyceal system rupture is distal obstruction by a ureteric calculus and should be included in the differential diagnosis of patients with acute flank pain and perinephric fluid on ultrasound and Contrast enhanced CT scan with delayed images should be done to confirm the diagnosis. We present a case of spontaneous non traumatic pelvicalyceal system rupture due to a tiny ureteric calculus managed with primary ureteroscopic lithotripsy.

Rare Case of Acute Renal Artery Thrombosis in Nephrotic Syndrome: The Unusual Presentations and Outcomes of Endovascular Manual Aspiration Thrombectomy

Renal artery thrombosis is a rare condition that requires early diagnosis and urgent intervention to prevent renal infarction and permanent renal damage. Possibility of renal artery thrombosis should be considered in patients with underlying hypercoagulable state presented with acute unremitting flank pain, nausea and vomiting. We report a case of a 35-year-old man with underlying nephrotic syndrome who presented with three days history of acute non-localized and non-resolving abdominal pain and vomiting. He was initially referred to general surgery for acute intestinal obstruction. Contrast-enhanced computed tomography (CECT) abdomen revealed acute left renal infarction secondary to total thrombotic occlusion of the left renal artery. The patient was treated with endovascular manual aspiration thrombectomy resulting in partial revascularization of left renal artery with restoration of renal function, complete resolution of symptom and good clinical outcomes. This case report serves as a reminder for physicians to include renal infarction in the differential diagnosis when evaluating a patient with acute abdomen, particularly in patient with hypercoagulable state. This case also aligns with other experiences demonstrating positive outcomes after endovascular thrombectomy, even in the presence of prolonged renal ischemia time of more than 72 hours.

Efficacy of Ayurveda medicine in renal calculi (Ashmari) with hydronephrosis: a case study

Abstract Introduction: Renal stone (Mutrashmari) is one of the most common diseases of Mutravaha Srotas (urinary system). It occurs when the formation of crystals, such as calcium, oxalate, uric acid, etc., takes place due to improper functioning of the filtration in the kidney. Case Study: The present study deals with a 20-year-old female patient having complaints of burning micturition, acute left flank pain in the abdomen and back which was radiating from the loin to the groin region, nausea, vomiting, dysuria. She was already diagnosed with renal calculi and was taking allopathic medications since for the last 1 month. Later she encountered the same problem and consulted an Ayurvedic physician. Ayurveda management primarily focuses on Samprapti Vighattana (breaking down the pathogenesis). Diagnosis: It was done on the basis of symptoms and USG reports. Intervention: By considering the Nidana, Dosha, and Dushya, a judicial combination of Ayurveda drugs-Gokshuradi Guggulu, Varunadi Kwatha, Tab. Cystone, Syp Neeri and Pasanbhedadi Churna were advised to take orally in morning and evening with lukewarm water. Outcomes: At the time of consultation her USG finding showed 8 mm calculus with nephrosis. After taking the prescribed formulation for 2 months, her USG report came to normal. Conclusion: The prescribed Ayurvedic herbal medicines are seen to be effective in managing the day-to-day life of an Ashmari patient.

Undifferentiated Renal Cell Carcinoma Presenting As Wunderlich Syndrome: A Case Report

Wunderlich syndrome is a spontaneous, non-traumatic, sub-capsular perinephric hematoma described by a triad of acute flank pain, the presence of flank mass, and hypovolemic shock. This acute syndrome is mostly caused by renal malignancies, particularly renal angiomyolipoma and renal cell carcinoma. Computed tomography (CT) scan is the preferred diagnostic modality for Wunderlich syndrome and its treatment depends on the cause. Herein, we present a 41- year-old male admitted with flank pain, who was subsequently found to have thrombocytosis, hematuria, and hypotension. A computed tomographic scan revealed a kidney mass and hematoma, which was removed. Biopsy of the mass revealed undifferentiated renal cell carcinoma and the mass caused malignant pleural effusion. This case report demonstrates increasing platelet counts, which raised concern for advanced malignancy and the triad of features may not always be present. It also highlights the etiology, clinical manifestation, and management of this syndrome.

Hematuria: Is it useful in predicting renal or ureteral stones in patient presenting to emergency department with flank pain?

The objective of the study was to evaluate hematuria as a diagnostic test for renal and ureteral stones compared with a noncontrast-enhanced computed tomography (CT) scan (gold standard test) in emergency room patients with acute flank pain. In total, 604 patients treated in our emergency department from 2006 to 2011, with a history of flank pain and suspected urolithiasis were included in a retrospective review. All patients were evaluated with a noncontrast-enhanced CT scan and urine analysis. Using the noncontrast CT scan as the gold standard for the evaluation of the presence, number, size, and site (renal or ureteral [upper, middle, and lower]) of the stones, we calculated the sensitivity, specificity, and positive and negative predictive values of hematuria for diagnosing both renal and ureteral stones. Urolithiasis was diagnosed in 388 patients (64%) and 216 patients (36%) had no stones on a noncontrast-enhanced CT scan. The sensitivity, specificity, positive predictive value, and negative predictive value for microhematuria were 77%, 33%, 67%, and 45%, respectively. Microhematuria was more common in patients with ureteral stones only (139 patients) and had a sensitivity of 85% compared to patients with renal stones only (32 patients), with a sensitivity of 55% (P < 0.001). There were no significant differences in the specificity or positive or negative predictive values. Although microhematuria is more sensitive to ureteral stones, the absence of microhematuria does not exclude the possibility of urolithiasis and a noncontrast-enhanced CT scan should be the gold standard diagnostic tool.

Spontaneous rupture of a benign renal cyst A rare and misleading cause of Wunderlich syndrome

Wunderlich syndrome (WS) is a rare condition characterized by acute onset of spontaneous renal hemorrhage into the subcapsular and perirenal spaces. Wunderlich syndrome is classically characterized by the Lenk's triad: acute flank pain, flank mass, and hypovolemic shock. In this vignette; we describe our experience with a previously healthy adult female who presented with loin pain for weeks followed by gross hematuria, anemia and hypotension. Ultrasound examination of the abdomen and pelvis revealed; (a) an ill-defined hyperechoic mass-like lesion measuring 4.6X4.1 cm at its upper pole of right kidney which, on doppler study, had minimal internal vascularity, (b) moderate perinephric hematoma, moderate hydroureter and hydronephrosis. Triphasic CT scan and MRI, with contrast, of the abdomen and pelvis disclosed a case of ruptured benign cyst and ruled out renal cancer and vascular etiologies. The patient was treated conservatively and did not require renal embolization or nephrectomy. In conclusion; ruptured renal cysts is a rare cause for WS yet requires prompt management with patient’s stabilization and diagnostic approach. Contrary to the more common etiologies viz. tumors and vasculopathy; it rarely requires more than conservative treatment in stable patients.

Renal Vein Thrombosis Occurring in Association with Oral Contraceptives: A Case Report

Peripheral venous thromboembolism is a well-known complication of hormonal contraception, but reports on its association with visceral vein thrombosis is limited. We report the case of left renal vein thrombosis (RVT) associated with oral contraceptives (OCs) and concurrent smoking. The clinical presentation of this patient was acute left flank pain. Computed tomography revealed left RVT. The OC was discontinued, and we initiated anticoagulation with heparin and switched to edoxaban. Computed tomography 6 months later showed complete resolution of the thrombosis. This report alerts us regarding the importance of OCs as a risk factor for RVT.

CT Use Reduction In Ostensive Ureteral Stone (CURIOUS)

IntroductionComputed tomography (CT) is performed in over 90% of patients diagnosed with ureteral stones, but only 10% of patients presenting to the emergency department (ED) with acute flank pain are hospitalized for a clinically important stone or non-stone diagnosis. Hydronephrosis can be accurately detected using point-of-care ultrasound and is a key predictor of ureteral stone and risk of subsequent complications. The absence of hydronephrosis is insufficient to exclude a stone. We created a sensitive clinical decision rule to predict clinically important ureteral stones. We hypothesized that this rule could identify patients at low risk for this outcome. MethodsWe conducted a retrospective cohort study in a random sample of 4000 adults who presented to one of 21 Kaiser Permanente Northern California EDs and underwent a CT for suspected ureteral stone from 1/1/2016 to 12/31/2020. The primary outcome was clinically important stone, defined as stone resulting in hospitalization or urologic procedure within 60 days. We used recursive partition analysis to generate a clinical decision rule predicting the outcome. We estimated the C-statistic (area under the curve), plotted the receiver operating characteristic (ROC) curve for the model, and calculated sensitivity, specificity, and predictive values of the model based on a risk threshold of 2%. ResultsAmong 4000 patients, 354 (8.9%) had a clinically important stone. Our partition model resulted in four terminal nodes with risks ranging from 0.4% to 21.8%. The area under the ROC curve was 0.81 (95% CI 0.80, 0.83). Using a 2% risk cut point, a clinical decision tree including hydronephrosis, hematuria, and a history of prior stones predicted complicated stones with sensitivity 95.5% (95% CI 92.8%–97.4%), specificity 59.9% (95% CI 58.3%–61.5%), positive predictive value 18.8% (95% CI 18.1%–19.5%), and negative predictive value 99.3% (95% CI 98.8%–99.6%). ConclusionsApplication of this clinical decision rule to imaging decisions would have led to 63% fewer CT scans with a miss rate of 0.4%. A limitation was the application of our decision rule only to patients who underwent CT for suspected ureteral stone. Thus, this rule would not apply to patients who were thought to have ureteral colic but did not receive a CT because ultrasound or history were sufficient for diagnosis. These results could inform future prospective validation studies.

The role of serum and urinary markers in predicting obstructing ureteral stones and reducing unjustified non-contrast computerized tomographic scans in emergency departments.

The reported yield of non-contrast computed tomography (NCCT) in assessing flank pain and obstructive urolithiasis (OU) in emergency departments (EDs) is only ~ 50%. We investigated the potential capability of serum and urinary markers to predict OU and improve the yield of NCCT in EDs. All consecutive ED patients with acute flank pain suggestive of OU and assessed by NCCT between December 2019 and February 2020 were enrolled. Serum white blood cells (WBC), C-reactive protein (CRP) and creatinine (Cr) levels, and urine dipstick results were analyzed for association with OU, and unjustified NCCT scan rates were calculated. NCCTs diagnosed OU in 108 of the 200 study patients (54%). The median WBC, CRP, and Cr values were 9,100/µL, 4.3mg/L, and 1mg/dL, respectively. Using ROC curves, WBC = 10,000/µL and Cr = 0.95mg/dl were the most accurate thresholds to predict OU. Only WBC ≥ 10,000/µL (OR = 3.7, 95% CI 1.6-8.3, p = 0.002) and Cr ≥ 0.95mg/dl (OR = 5, 95% CI 2.3-11, p < 0.001) were associated with OU. Positive predictive value and specificity for detecting OU among patients with combined WBC ≥ 10,000 and Cr ≥ 0.95 were 83% and 89%, respectively. Patients negative to the serum markers criteria underwent significantly more unjustified NCCTs (p = 0.03). The negative predictive value of the serum criteria for justified NCCT scanning was 81%. WBC and Cr may be valuable serum markers in predicting OU among patients presenting to EDs with acute flank pain. They may potentially reduce the number of unjustified NCCT scans in the ED setting.

Post-Partum Flank Pain: Think Renal Vein Thrombosis - Case Report

Renal vein thrombosis (RVT) in the post-partum period is rarely reported. It is majorly a complication of the hypercoagulability associated with both pregnancy and postpartum state. We report the case of a primiparous 19-year-old woman, who presented to the Emergency Department complaining of acute right flank pain. Doppler ultrasonography revealed thrombosis of the right renal vein with extension into the inferior vena cava (IVC). Contrast-enhanced abdominal computerized tomography (CT) confirmed the diagnosis. The outcome was favorable after anticoagulation therapy by Heparin was initiated. Practitioners need to be aware of the diagnosis of RVT. Imaging tests, especially contrast CT scans play a major role in the diagnosis and post-therapeutic assessment.

Homoeopathy and Renal Stone: An Evidence-Based Clinical Case Report of Non-Surgical Renal Stone Expulsion

Renal stone is the most common urinary tract disease found worldwide. The prevalence of renal stone disease has increased considerably in the past few decades. Changes in lifestyle, faulty diet, too much psychological stress, and environmental factors are possible predisposing factors. Some patients may be asymptomatic or have atypical symptoms such as vague abdominal pain. In contrast, others will have more typical symptoms, such as acute abdominal or flank pain, nausea, urinary urgency, or frequency. The approach in conventional treatment gives no permanent solution. Homoeopathic constitution medicine treats the patient as a whole and seizes the recurrence. This article illustrates a case report of successful non-surgical expulsion of renal calculus by homoeopathic medicine to show the potentiality of homoeopathic medicines. 1,2

Association between Renal Stones Sonographic Findings and Demographic Data among Patients at Riyadh Hospitals, Saudi Arabia

Background: Ultrasound is the primary imaging modality to identify renal stones (RS) in patients with acute flank pain. This study aimed to evaluate the presence, location, and size of RS diagnosed by ultrasound in association with age, gender, and BMI among patients at Riyadh hospitals. Methods and Results: In this case-control study, a total of 250 records (130/52% for males and 120/48% for females) from 2018 to 2019 were reviewed from January to March 2020 at different hospitals in Riyadh. In this study, 150(60%) records of patients with RS and 100(40%) records of patients without RS were collected to evaluate the risk factor for RS formation in the central area of Saudi Arabia. A designed data collection sheet containing all variables (demographic and sonographic) of the study was used. Demographic data included gender, age, and body mass index (BMI). Sonographic data included RS presence (yes, no), RS location (right kidney [RK], left kidney [LK], both kidneys), and RS size (small [&lt;0.5cm], average [0.5–1cm], and large [&gt;1cm]). The study found that RS were more common among males than females (P&lt;0.001). The results show that in normal BW, the frequency of stone presence was similar for RK and LK. In overweight patients, RS were more often observed in LK (P=0.000). We also found a significant association between BMI and RS size (P=0.049); the presence of smaller stones increases with BMI. There was no association between sonographic data and age (P&gt;0.05) Conclusion: Among patients at Riyadh hospitals, females are less affected by RS than males. Gender is a significant risk factor for the development of RS. The effect of BMI is obvious on renal stone location and size.

PSAT029 Acute Presentations of 4 Patients with Spontaneous Adrenal Hemorrhage

Abstract Case 1 A 19 year old primigravida, 35 weeks gestation, presented with acute severe right flank pain and vomiting. She underwent a MR cholangiopancreatography following advice from the gastroenterologists. This revealed a right adrenal gland haemorrhage 46×24×40 mm. CRP was raised at 151mg/l. Random cortisol, potassium and plasma metanephrines (pMET) were normal. She was delivered by Caesarian Section at term with 100 mg IV hydrocortisone cover and with no complications to either mother or baby. CT adrenals performed 8 weeks postpartum was entirely normal with no evidence of residual haemorrhage or adrenal mass. Case 2 A 63 man with hypertension presented with acute severe left flank pain. CT renal and CT angiogram showed a large left adrenal and perinephric haemorrhage. This was treated with coil embolization of the left suprarenal artery. Initial biochemistry showed mildly raised plasma normetanephines at 2211 pmol/l which subsequently normalised. Overnight dexamethasone suppression test (ONDST) and aldosterone/plasma renin activity were normal. Serial CT scan showed gradual resolution of the adrenal haemorrhage with no underlying adrenal lesion. Case 3 A 56 year old man presented with a 3 day history of epigastric and left sided abdominal pain with nausea and fever. CT scan of the abdomen revealed a 5 cm adrenal haemorrhage which was contained within the gland. ONDST, pMET and aldosterone/plasma renin activity were normal. Serial scans showed resolution of the adrenal haemorrhage and a residual 14×13 mm adrenal nodule with a density of 20 Hounsfield Units but which remained unchanged in size. Case 4 A 72 year old man with generalised abdominal pain a week after hip replacement surgery. He developed a fever and his inflammatory markers were raised. CT abdomen showed non-enhancing bilateral adrenal lesions consistent with adrenal haemorrhage. He was taking Apixaban for thromboprophylaxis following hip replacement. A short synacthen test performed to rule out adrenal insufficiency showed a suboptimal cortisol response and treatment with hydrocortisone was commenced. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

141 Frequency of Computed Tomography When Point-of-Care Ultrasound Is Performed for Acute Flank Pain in the Emergency Department

Renal point-of-care ultrasound (POCUS) has become increasingly utilized as an initial imaging modality for patients who present to the emergency department (ED) with suspected renal colic. Despite the widespread use of POCUS for this indication, the way in which ultrasound findings impact downstream ED testing, consultation, and admission or discharge remains unclear. The aim of this study is to describe the frequency of ordering abdominal computed tomography (CT) scans in a single, academic ED, when point-of-care ultrasound is performed for suspected renal colic.

Man With Left Flank Pain

An 81-year-old man with a peripheral vascular disease presented to the emergency department with acute left flank pain for several hours that resolved after oral analgesia. He was hemodynamically stable, and his abdomen and flank were soft and nontender. Laboratory tests included an acutely increased creatinine level of 1.5 mg/dL. A bedside ultrasound demonstrated a hyperechoic left kidney with perinephric fluid and an abdominal aortic aneurysm of 8 cm (Figure 1). Abdominal computed tomography demonstrated an abdominal aortic aneurysm with aorto-left retroaortic renal vein fistula and secondary renal vein infarction with decreased parenchemal enhancement and perinephric fluid (Figure 2).

Left Flank Pain and Hydronephrosis as the Initial Presentations of Advanced Gastric Cancer

Ureteric obstruction is rarely noted in cases of gastric cancer. Its involvement by distant metastasis from gastric adenocarcinoma without direct invasion is an exceptionally unusual occurrence. This is the story of a 58-year-old man who arrived at the emergency department with acute flank pain and fever. He was initially diagnosed with obstructive pyelonephritis after the discovery of a new onset, complete ureteric obstruction on the left side. Subsequent investigations and follow-up revealed the presence of gastric adenocarcinoma with possible ureteric metastasis bilaterally, flank pain and hydronephrosis were the first and only presentations of gastric cancer. The rarity of the condition and the unusual presentation encouraged us to report the case.