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Flank Pain

History
A 33 year old man presents with continuous pain in the left flank
for one day, which progressively worsened over time, and was
only minimally responsive to Ibuprofen.
There was no history of fever, urinary symptoms or recent or
past trauma to the affected area.
His medical and surgical histories are unremarkable. He only
drinks socially and does not smoke.

Physical
VS: BP 105/70 HR 110T 98.2F RR 16 SpO2 97%
General: WM in acute distress
HEENT: PERRLA, EOM intact. No noticeable or palpable swelling in neck, trachea midline. No LAD appreciated.
Cardiovascular: RRR; very soft systolic ejection murmur but no r/g, no JVD, no carotid bruits.
Lungs: CTAB, no use of accessory muscles, no crackles , wheezing, or rhonchi.
Skin: w/o lesions, scars, ulceration, or erythema
Abdomen: Normoactive BS, abdomen soft and non-tender. No pain on palpation.

Genital-Urinary: Not performed


Rectal: Not performed
Extremities: No edema, cyanosis or clubbing, and no swollen or erythematous joints.
Neurological: Alert and oriented x 3, CN 2-12grossly intact.

What is part of the DDx?


A. Nephrolithiasis
B. AAA
C. Renal Artery Aneurysm
D. Renal hemorrhage
E. Renal Artery Stenosis
F. Acute Pyelonephritis
G. Bleeding into Renal Cyst
H. C,D, and E only
I. B, D, and E only
J. A-G are all correct
K. None of the above

What is part of the DDx?


A. Nephrolithiasis
B. AAA
C. Renal Artery Aneurysm
D. Renal hemorrhage
E. Renal Artery Stenosis
F. Acute Pyelonephritis
G. Bleeding into Renal Cyst
H. C,D, and E only
I. B, D, and E only
J. A-G are all correct
K. None of the above

LABS
BUN: 17 mg/dL (3 - 20)
Cr: 1 mg/dL (0.5 - 1.2)
UA:
WBCs: 0/hpf
Erythrocytes: 10 - 12/hpf
No cell casts or crystals

Imaging
Non-contrast CT abdomen
There are no renal or ureteric stones. The abdominal aorta appears
normal.

CT angiogram
There is a dilation in the distal portion of the left renal artery. A
hemorrhage is noted in the superior pole of the left kidney, with ~65%
necrosis of the parenchyma.

What is the most likely diagnosis?


A. Nephrolithiasis
B. Acute Pyelonephritis
C. Renal Artery Aneurysm
D. AAA
E. Ureteral Calculi

What is the most likely diagnosis?


A. Nephrolithiasis
B. Acute Pyelonephritis
C. Renal Artery Aneurysm
D. AAA
E. Ureteral Calculi

Supporting Findings
No history of trauma
Patient is afebrile, and denies n/v/d; also no WBCs per hpf on UA;
acute pyelonephritis unlikely
Non-radiating constant pain does not support ureteral stones but
large elevation in erythrocytes may be suggestive of staghorn
calculi; non-contrast CT ruled this out
CT angiogram allowed for reno-vascular pathology to be explored,
which should hemorrhage at left pole of kidney from ruptured
renal artery aneurysm

QUESTION: ACE Inhibiters would be


appropriate treatment at this time.
A. True
B. False

QUESTION: ACE Inhibiters would be


appropriate treatment at this time.
A. True
B. False
ACE Inhibitor will reduce perfusion to the kidney, exacerbating the
infarction.

Anatomic Correlation

There are 3 different types of RAA:


Type 1: Saccular RAAs stemming from
renal artery or one of its branches
Type 2: Fusiform RAAs
Type 3: Intralobar RAAs, stemming
from small segmental arteries which
supply limited region of the
parenchymal tissue of the kidney

Management

NPO
IM Opioids
Coil Embolization for more distal aneurysms
Open surgical intervention for more proximal aneursyms

What is recommended when intervention is


not indicated?
A. Intervention is always indicated
B. Corticosteroids
C. Nutritional therapy
D. Follow up annually w/ Doppler U/S or non-contrast CT
E. None of the above

What is recommended when intervention is


not indicated?
A. Intervention is always indicated
B. Corticosteroids
C. Nutritional therapy
D. Follow up annually w/ Doppler U/S or non-contrast CT
E. None of the above

Summary of RAA
RAA is usually found incidentally as it is quite rare
The gold standard for diagnosis is a CT angiogram
Surgical repair is usually associated with higher rates mortality
when compared to endovascular methods

References
Henke P.K, Cardneau J.D, Welling III T.H, Upchurch Jr. G.R, Wakefield T.W, Jacobs L.A, Proctor S.B,
Greenfield L.J, Stanley J.C. (2001). Renal artery aneurysms - A 35-year clinical experience with 252
aneurysms in 168 patients. Annals of surgery. 234 (4), p454-463
Kumar P, Clarke M. (2009). Renal disease. Clinical medicine. 7th edition, p571-575
Moreiraa N, Pgo M, Carvalheiro V, Agostinho A, Donato P, Pego J, Ferreira M.J, Providncia L.
(2012). Renal artery aneurysm: An endovascular treatment for a rare cause of hypertension. Rev Port
Cardiol. 31 (10), p667-670
Nosher J.L, Chung J, Brevetti L.S, Graham A.M, Siegel R.L. (2006). Visceral and renal artery
aneurysms: A pictorial essay on endovascular therapy. Radiographics. 26, p1687-1704
Prevljak S, Carovac A, Jakirlic N. (2012). Case report: Renal artery aneurysm. Med. Arh. 66 (5), p355356
Sdat J, Chau Y, Baque J. (2012). Endovascular treatment of renal aneurysms: A series of 18 cases.
European journal of radiology. 81, p3973-3978
Stojanovi M, Pena-Karan S, Joves-Sevi B, Ili T, Ili M. (2012). Aortic dissection or renal infarction:
multislice computed tomographic angiography can tell. Srp Arh Celok Lek. 140 (9-10), p644-647

Any Questions?