Immediate Next Step: Non-Contrast CT Scan of Abdomen/Pelvis
This 21-year-old male requires urgent imaging with non-contrast CT scan of the abdomen and pelvis to evaluate for nephrolithiasis (kidney stones), which is the most likely diagnosis given his age, symptom pattern, and urinalysis findings. 1
Clinical Reasoning
Why Imaging is Essential
The urinalysis findings of trace lysed blood on macroscopic examination with only 1-2 RBCs on microscopy is consistent with urolithiasis - this pattern of minimal microscopic hematuria does not exclude significant urologic pathology 1
Lower abdominal and back pain in a young male with any hematuria (even trace) requires imaging to confirm or exclude urolithiasis, as this cannot be diagnosed with certainty on clinical grounds alone 1
Non-contrast CT is the gold standard imaging modality for suspected urolithiasis and should be obtained promptly in this clinical scenario 1
Why This Takes Priority Over Migraine Considerations
While the patient has a migraine history, several factors make this an inadequate explanation for his current presentation:
Abdominal migraine, though possible in adults, is a diagnosis of exclusion that requires ruling out all alternative diagnoses first 2, 3
The presence of hematuria (even trace amounts) is NOT a feature of abdominal migraine and mandates investigation for urologic pathology 2, 3
Lower back pain combined with abdominal pain and hematuria forms a classic triad for nephrolithiasis, which is far more common in this demographic than abdominal migraine 1
Abdominal migraine typically presents with periumbilical pain, not lower abdominal pain with back radiation, and would not explain the urinalysis findings 2, 3
Immediate Management Algorithm
Step 1: Obtain Imaging
- Order non-contrast CT scan of abdomen and pelvis immediately to evaluate for urolithiasis 1
Step 2: Symptomatic Treatment While Awaiting Results
- Administer ketorolac 30-60 mg IM for pain control - this NSAID is highly effective for renal colic and has minimal rebound headache risk 4
- Provide antiemetic if nausea present (metoclopramide 10 mg IV or prochlorperazine 10 mg IV) 5
Step 3: Additional Laboratory Testing
- Complete blood count and C-reactive protein to assess for infection or inflammation 1
- Serum creatinine to evaluate renal function 1
- Consider creatine phosphokinase (CPK) if rhabdomyolysis is a concern, though the urinalysis pattern (trace blood with minimal RBCs) is not classic for this diagnosis 6
Critical Pitfall to Avoid
Do not dismiss the hematuria as insignificant simply because microscopy shows only 1-2 RBCs. The combination of positive dipstick for blood with minimal microscopic RBCs can occur with:
- Dilute urine causing RBC lysis 6
- Small stones causing intermittent bleeding 1
- Early presentation before significant hematuria develops 1
If Imaging is Negative
Only after urolithiasis and other structural causes are definitively excluded should abdominal migraine be considered:
Abdominal migraine diagnosis requires: recurrent episodes of periumbilical pain lasting 1-72 hours, normal physical examination between episodes, exclusion of all alternative diagnoses, and typically a strong family history of migraine 2, 3
Treatment for confirmed abdominal migraine would include: NSAIDs as first-line (ibuprofen 400-800 mg), with triptans as second-line if NSAIDs fail 7
Prophylactic therapy should be initiated if attacks occur ≥2 days per month despite acute treatment 7