A8) Flank pain and hematuria

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with flank pain.
  2. Review DDx considerations in a patient with flank pain.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with flank pain.


Physical Exam


Provisional Diagnosis

Select the Dx you believe is most appropriate
The colicky flank pain radiating to the groin, with costovertebral angle tenderness suggests renal colic from obstruction of the ureter. In this young patient with a history of hyperparathyroidism (results in hypercalciuria) and celiac disease (results in hyperoxaluria), it is likely secondary to a kidney stone.
Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Well done. You were correct
Considering the patient has acute kidney injury (Cr >1.5x baseline), they require expedited workup.

First Imaging Study

What is the first imaging study you will order?

An abdominal CT without contrast is the gold standard for identifying and characterizing renal stones. The pelvis should also be included to assess for stones in the lower ureter, ureterovesical junction, and the bladder.
Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Watch our video

View the full study if you'd like to take a look yourself.

Second Imaging Study

What is the next imaging study you will order?

No further imaging is required.
Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

The patient’s history of hyperparathyroidism (which leads to hypercalciuria) and celiac disease (which leads to hyperoxaluria) and the bright stone on CT suggest this is a calcium oxalate stone.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Considering the hydronephrosis secondary to the obstructing stone, the patient requires prompt treatment initialization.

Assessment and Plan

Please provide your assessment and plan for this patient

This is a young female presenting with renal colic, nausea, vomiting, and hematuria secondary to an obstructing UPJ stone leading to hydronephrosis. She requires urgent urological evaluation and will likely require a urologic procedure considering the size and sequelae secondary to the stone. She will also require imaging follow-up to assess the incidentally noted pulmonary nodules.

Lessons Learned:
- Non-contrast CT of the pelvis and abdomen is the gold standard for diagnosis of nephrolithiasis.
- Stones are most often lodged in the renal collecting system’s three sites of anatomical narrowing: ureteropelvic junction (UPJ), crossing of the ureter over the iliac vessels, and the ureterovesical junction (UVJ)
- Stones ≥ 10cm are unlikely to pass.

Socioeconomic Factors: Patients with lower educational levels and from regions with low mean income are more likely to have greater stone burden.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator