15. Right Upper Quadrant Pain

Question 1

List the differential diagnosis for RUQ pain.

Answer 1

Biliary colic 
Cholecystitis 
Duodenal ulcer 
Ascending cholangitis
Pancreatitis
Basal pneumonia

Question 2

Other than the SOCRATES questions, list some other questions that you may ask about the history of presenting complaint to help you narrow the differential diagnosis.

Answer 2

Have there been any OTHER SYMPTOMS other than the pain?
Fever – indicates infection
Unintentional weight loss – systemic feature of malignancy

Have you noticed any CHANGE IN YOUR STOOL?
Steatorrhoea – suggests biliary obstruction
Melaena – suggests upper GI bleed

Is there any chance that you may be PREGNANT?

Question 3

What is steatorrhoea caused by?

Answer 3

Biliary obstruction meaning that bile no longer reaches the duodenum

Question 4

List two causes of RUQ pain that are exclusive to pregnancy.

Answer 4

Cholestasis of pregnancy

Pre-eclampsia

Question 5

Why is it important to check whether a patient with RUQ pain could be pregnant?

Answer 5

X-rays and CTs must be carefully considered in a patient who is pregnant
Ectopic pregnancies can cause abdominal pain (though it is unlikely to cause RUQ pain)

Question 6

List some causes of post-hepatic jaundice.

Answer 6

Choledocholithiasis
Ascending cholangitis
Acute pancreatitis 
Pancreatic cancer
Cholangiocarcinoma

Question 7

What do Grey Turner’s and Cullen’s sign indicate?

Answer 7

Severe pancreatitis

Question 8

What is Murphy’s sign?

Answer 8

Palpate the abdomen just below the tip of the right 9th costal cartilage
Ask the patient to breathe in deeply
Inspiration will be halted when an inflamed and tender gallbladder strikes your finger
A positive Murphy’s sign suggests cholecystitis

Question 9

Describe the features of a peritonitic patient on examination.

Answer 9

Still
Rigid abdomen that is exquisitely tender
Guarding 
Rebound tenderness
There may be no bowel sounds

Question 10

Describe the signs of bowel obstruction on examination.

Answer 10

Distended abdomen
Tinkling bowel sounds
Signs of peritonitis if the bowel is strangulated or perforated

Question 11

List some important investigations for patients with RUQ pain.

Answer 11

FBC
Serum amylase/lipase
Liver enzymes (ALT, AST, ALP, GGT and BR)

Question 12

What can cause a moderate elevation of amylase levels?

Answer 12

Pretty much anything that can go wrong in the abdomen 
Bowel obstruction
Mesenteric ischaemia 
Pancreatic cancer 
Opiate medications

Question 13

What does high AST + ALT indicate?

Answer 13

This is called transminitis

Suggests damage to hepatocytes (e.g. by viral hepatitis, autoimmune hepatitis)

Question 14

What does high ALP indicate?

Answer 14

High ALP alone could come from bone (e.g. after a fracture)
High ALP that is more elevated than AST/ALP and/or accompanied by raised GGT suggests obstruction of the common bile duct (cholestatic picture)

Question 15

What does isolated high GGT indicate?

Answer 15

Alcohol abuse

Question 16

What can cause unconjugated hyperbilirubinaemia?

Answer 16

Increased bilirubin production (e.g. due to haeomlysis)

Hereditary deficiency of conjugating enzyme (e.g. Gilbert’s syndrome)

Question 17

What can cause conjugated hyperbilirubinaemia?

Answer 17

Obstruction to bile outflow that is either:
INSIDE the liver (e.g. primary biliary cirrhosis)
OUTSIDE the liver (e.g. choledocholithiasis)

Question 18

Why may an erect chest X-ray be performed in a patient with RUQ pain?

Answer 18

It may show air under the diaphragm, which would indicate that there is a perforated viscus (e.g. peptic ulcer)

Question 19

What may be picked up on ultrasound of the pancreas, common bile duct and gallbladder that may indicate the cause of RUQ pain?

Answer 19

Thickened, inflamed gallbladder wall

Dilation of ducts (> 6 mm is abnormal)

Question 20

What sign may be seen on an abdominal radiograph in a patient with bowel perforation?

Answer 20

Rigler’s sign

This is when air is present on both sides of the intestinal wall – suggests that there has been a perforation

Question 21

List the five main risk factors for the development of gallstones.

Answer 21

Fat 
Female 
Fair
Fertile
Forty

Question 22

Describe the different types of pain caused by cholecystitis based on the part of the peritoneum affected.

Answer 22

Irritation of the visceral peritoneum in the initial stages of the disease produces a poorly localised, dull, midline epigastric pain
Irritation of the parietal peritoneum causes a constant, better-localised pain

Question 23

The spread of inflammation to the liver capsule can lead to referred pain to what part of the body?

Answer 23

Shoulder-tip
This is because liver capsule irritation leads to irritation of the diaphragm, which is supplied by the phrenic nerve (C345)
The C345 dermatome supplies the shoulder tip

Question 24

List some complications of cholecystitis.

Answer 24

Gallstone ileus
Empyema
Cholecystoduodenal fistula
Gallbladder carcinoma

Question 25

List the non-operative steps in the management of a cholecystitis patient.

Answer 25

Only clear fluids by mouth
IV fluids
Analgesia
Antibiotics

Question 26

What operation will be performed in patients with cholecystitis?

Answer 26

Laparoscopic cholecystectomy

Question 27

What is Charcot’s triad?

Answer 27

RUQ pain
Jaundice
Fever with rigors

Question 28

What is ascending cholangitis?

Answer 28

Inflammation of the common bile duct because of an infected stone in the common bile duct or due to spread of infection from an infected gallbladder

Question 29

Describe the management of ascending cholangitis.

Answer 29

It is a SURGICAL EMERGENCY
Blood cultures
Antibiotics
ERCP – relieve the blockage to bile flow
Monitor and watch out for sepsis
Definitive management – elective cholecystectomy

Question 30

What is biliary colic usually caused by?

Answer 30

Cholelithiasis (presence of gallstones in the biliary tract)

Question 31

What is Hartmann’s pouch?

Answer 31

It is the area where the gallbladder meets the cystic duct

NOTE: gallstones irritating Hartmann’s pouch or the CBD can cause a sharp, stabbing pain (biliary colic)

Question 32

Describe the symptoms that could result from bleeding peptic ulcers.

Answer 32

Epigastric pain or RUQ pain

Melaena

Question 33

List some forms of imaging that may be used to investigate bleeding peptic ulcers.

Answer 33

OGD
CT angiogram
Video capsule endoscopy
Red cell scan