From the Guidelines
When a CT scan of the abdomen is negative in a patient with left-sided flank pain, the next step should be a comprehensive clinical reassessment to determine the underlying cause, including a detailed history and physical examination, followed by targeted laboratory tests and additional imaging studies as needed, such as ultrasound or MRI, as suggested by recent guidelines 1.
Clinical Reassessment
This should include a detailed history focusing on pain characteristics, associated symptoms, and risk factors. A thorough physical examination is also crucial to identify any potential causes of the pain.
Laboratory Tests
Laboratory tests such as complete blood count, comprehensive metabolic panel, urinalysis, and inflammatory markers (ESR, CRP) should be ordered if not already done. These tests can help identify potential causes of the pain, such as infection or inflammation.
Additional Imaging Studies
Depending on the clinical suspicion, additional imaging studies may be warranted. For example, ultrasound can be used to evaluate for musculoskeletal or vascular causes, while MRI can provide better soft tissue visualization. A CT urogram may be necessary if urological pathology is suspected, as it can help identify stones or other abnormalities in the urinary tract, as noted in the guidelines for acute onset flank pain-suspicion of stone disease (urolithiasis) 1.
Specialist Consultation
Consultation with specialists like gastroenterology, urology, or gynecology (in female patients) may be necessary based on the evolving clinical picture. This is because left flank pain has numerous potential causes, including renal, gastrointestinal, musculoskeletal, and reproductive system disorders, some of which may not be readily apparent on a standard CT scan.
Importance of a Stepwise Approach
This stepwise approach is important because it allows for a thorough and systematic evaluation of the patient's symptoms, reducing the risk of missing a potential cause of the pain. By following this approach, clinicians can ensure that they are providing the best possible care for their patients, as supported by recent studies on the evaluation of acute onset flank pain 1.
From the Research
Next Steps in Evaluating Left-Sided Flank Pain
After a negative computed tomography (CT) scan of the abdomen, the next steps in evaluating left-sided flank pain may include:
- Considering other potential causes of flank pain, such as nephrolithiasis, pyelonephritis, or other renal pathologies 2
- Utilizing other imaging modalities, such as magnetic resonance imaging (MRI) or contrast-enhanced ultrasound (CEUS), to further evaluate the kidneys and surrounding structures 3
- Evaluating for other potential causes of left-sided abdominal pain, such as primary epiploic appendagitis or colonic diverticulitis 4
- Using point-of-care ultrasound (PoCUS) to assess for hydronephrosis or other renal causes of pain 5
Diagnostic Considerations
When evaluating left-sided flank pain, it is essential to consider a broad range of potential causes, including:
- Renal pathologies, such as nephrolithiasis or pyelonephritis
- Gastrointestinal pathologies, such as primary epiploic appendagitis or colonic diverticulitis
- Other potential causes, such as musculoskeletal or vascular pathologies
Imaging Modalities
Various imaging modalities can be used to evaluate left-sided flank pain, including: