left sided colicky sharp pain sudden onset
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left flank colicky pain differential diagnosis
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Here is a structured clinical overview of left-sided colicky sharp pain with sudden onset, drawing from Bailey & Love, S Das Manual, Pye's Surgical Handicraft, and Tintinalli's Emergency Medicine.
Left-Sided Colicky Sharp Pain - Sudden Onset
Differential Diagnosis by Region
1. LEFT FLANK / LOIN - Ureteric/Renal Colic (Most Common)
Pathophysiology: Hyperperistalsis of ureteric smooth muscle against an obstructing calculus causes acute, excruciating pain. Stones most commonly lodge at the pelviureteric junction, pelvic brim, or vesicoureteric junction (UVJ).
Classic Features:
- Sudden severe pain in the loin radiating to the groin, scrotum (or labia majora), and inner thigh (genitofemoral nerve, L1-L2)
- Ipsilateral testis may be drawn upward
- Associated nausea, vomiting, profuse sweating
- Restlessness - patient cannot find a comfortable position (unlike peritonitis where patient lies still)
- Microscopic haematuria (supports diagnosis)
- Frequency/strangury when stone at lower ureter near UVJ
Examination: Mild renal angle tenderness; bowel sounds may be reduced (reflex ileus)
Investigations:
- Urinalysis (haematuria)
- Non-contrast CT urinary tract (first-line - detects >95% of stones, including radiolucent uric acid stones)
- Renal ultrasound (if iodine allergy or pregnancy)
- IVU within 12 hours of onset (older recommendation)
Key point from Bailey & Love: "Small 3- to 5-mm calculi are usually responsible for ureteric colic and commonly lodge at the UVJ." Stones ≤5 mm have a 95% chance of spontaneous passage.
Management:
- NSAIDs (diclofenac, indomethacin) - first-line analgesia
- Adequate (not excessive) hydration
- Alpha-blockers (tamsulosin) as medical expulsive therapy for distal stones
- Surgical if: complete obstruction, solitary kidney, infection above obstruction, stone >10 mm, failure to pass
2. LEFT ILIAC FOSSA - Colonic/Diverticular Causes
| Condition | Features |
|---|---|
| Diverticulitis | LIF pain + fever, altered bowel habit, elderly/middle-aged, 50% with previous similar episodes; may be colicky early then persistent. CT sens 93%, spec ~100% |
| Sigmoid volvulus | Sudden onset colicky pain, gross abdominal distension, absolute constipation |
| Intestinal obstruction | Colicky pain, vomiting, distension, constipation; history of prior abdominal surgery |
| Epiploic appendagitis | LLQ, middle-aged male, fever unusual, self-limiting |
3. LEFT ILIAC FOSSA (FEMALES) - Gynaecological Emergencies
| Condition | Features |
|---|---|
| Ectopic pregnancy | Sudden severe left adnexal pain, amenorrhoea, vaginal bleeding, haemodynamic instability; positive serum beta-hCG. Risk factors: previous ectopic, PID, IUD |
| Ovarian torsion | Sudden-onset severe unilateral pain, often with nausea/vomiting; may have palpable adnexal mass; Doppler USS shows absent ovarian flow |
| Ruptured ovarian cyst | Sudden sharp pain at time of rupture; may have peritoneal signs |
From Tintinalli's (Table 71-4): Ectopic pregnancy presents as RUQ or LLQ with sudden onset, severe pain.
4. Broader Differentials Not to Miss
| Condition | Distinguishing Feature |
|---|---|
| Leaking/Ruptured AAA | Older male, pulsatile abdominal mass, haemodynamic shock - can mimic ureteric colic |
| Pancreatitis | Epigastric radiating to back, elevated lipase/amylase |
| Lead colic | Occupational exposure (painter), blue line on gums, severe constipation |
| Intestinal ischaemia | Pain disproportionate to signs, AF history, elderly |
| Clot colic | On anticoagulants/haemophilia - passing blood clots down ureter |
| Papillary necrosis | Diabetic/NSAID user/sickle cell disease |
Diagnostic Approach Summary
Left-sided colicky sharp pain - sudden onset
├── LOIN/FLANK → Ureteric colic (CT KUB, urinalysis)
├── LIF + fever → Diverticulitis (CT abdomen/pelvis)
├── LIF + female → Ectopic, ovarian torsion (serum hCG, pelvic USS)
├── LIF + distension → Obstruction / Volvulus (AXR, CT)
└── Haemodynamic instability → Leaking AAA (urgent USS/CT)
Key clinical rule from Bailey & Love: In suspected ureteric colic, "pelvic examination is especially important in women to exclude tubo-ovarian pathology such as an ectopic pregnancy or twisted ovarian cyst."
Always exclude AAA in older patients - a leaking aneurysm can present with classic loin-to-groin pain mimicking ureteric colic.
Sources: Bailey and Love's Short Practice of Surgery 28th Ed, p. 82; S Das Manual on Clinical Surgery 13th Ed, p. 485; Pye's Surgical Handicraft 22nd Ed; Tintinalli's Emergency Medicine, Table 71-4
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