Flank pain in a 60-year-old man

Problem 15 Flank pain in a 60-year-old man

A 60-year-old man presents with an 8-hour history of left flank pain. This had a sudden onset and the pain ‘comes in waves’. Over the last couple of hours, the pain has worsened, and in the last hour he feels nauseated and describes uncontrollable shivers and shakes.

Q.1

What further history would be appropriate?

The patient has never had pain like this before and is usually in good health apart from type II diabetes for which he takes metformin. His past history is unremarkable. On examination, he looks ill, is pale and diaphoretic, and the pain makes him appear uncomfortable. His temperature is 38.7°C, and he has a heart rate of 95/min, blood pressure of 90/60 mmHg, respiratory rate 23/min and an SaO₂ 91% breathing room air. His BMI is 30. His abdomen is soft to palpation, with no localizing signs.

His white cell count is 21 (91% neutrophils), creatinine 380 mmol/L, potassium 4.5 mmol/L and blood glucose 12 mmol/L. Urinalysis shows large amounts of red and white blood cells, and nitrites. An ECG is performed and confirms sinus tachycardia with no acute ST changes.

Q.2

What is your diagnosis and immediate management?

Two large-bore intravenous cannulae are inserted and a broad-spectrum antibiotic (ceftriaxone) is administered after blood and urine cultures have been obtained. Opiate analgesia and an antiemetic are given. A fluid balance chart and insulin sliding scale is commenced. After an hour and 2 litres of isotonic saline the patient is comfortable and his vital signs have stabilized. You can now turn your thoughts to looking for the cause of the sepsis.

Q.3

In general, what are the risk factors for sepsis?

Q.4

What are the possible underlying causes for sepsis in this man?

Now that the patient’s condition has stabilized some further investigations can be considered.

Q.5

What imaging would be appropriate at this stage?

A non-contrast CT scan is performed and two representative slices are shown in Figure 15.1A, B.

Figure 15.1A

Figure 15.1B

Q.6

What do these CT images show?

The CT scan findings confirm the clinical impression of urosepsis with a stone obstructing the left renal tract.

Q.7

How does a ureteric stone cause renal colic, and what other urinary symptoms may be present?

Q.8

How do you manage his pain?

Q.9

What factors are important in determining whether a stone will pass spontaneously?

Q.10

What are the indications for urgent procedural intervention?

Once the patient is stabilized, a ureteric stent is inserted under general anaesthetic via cystoscopy and frank pus drains from the left kidney. A specimen is sent for microscopy and culture and grows Escherichia.

The pain resolves rapidly and within 24 hours the patient’s temperature, creatinine and potassium are all within normal limits. Antibiotics are continued intravenously for 5 days total, and the patient is discharged with 10 days of oral antibiotics.

He is readmitted 2 weeks later for a ureteroscopy after his urine is confirmed to be sterile.

Tags: Clinical Problems in Medicine and Surgery

Apr 2, 2017 | Posted by admin in GENERAL SURGERY | Comments Off

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