Right Upper Quadrant Pain Flashcards
What are RUQ pain differentials for a youngish person gastro?
- Biliary colic
- Cholecystitis
- Duodenal cancer
- Pancreatitis
- Ascending cholangitis
- Gastric ulcer
- SBO
- Appendicitis
- Hepatitis
- Fitz-hugh-curtis syndrome
What are RUQ pain differentials for a youngish person non gastro?
- Basal pneumonia
2. Pyelonephritis
What questions do you need to ask about RUQ?
- Socrates
2. Symptoms other than pain e.g. fever, weight loss
What assoicated symptoms questions do you ask about and why?
- Last open their bowel or pass any flatus - absolute constipation obstruction
- Any change in stool recently - CBD obstructed (steatorrhea), Bleeding ulcer (melaena)
- Pregnancy - ectopic?
What signs do you look for on examination of RUQ pain?
- Jaundice
- Cullens or Greys sign
- Pulsatile laterally expansive central mass
- Murphy’s sign
- Peritonitis
- Signs of SBO
What would jaundice with RUQ pain suggest?
- choledocholithiasis
- asceding cholangitis
- acute pancreatitis
- pancreatic cancer
- cholagiocarinoma
What would cullen’s or grey turner’s sign with RUQ pain suggest?
acute haemorrhagic pancreatitis
What would a pulsatile laterally expansive central mass with RUQ pain suggest?
AAA
What is Murphy’s sign?
- palpate abdomen just below tip of right ninth costal cartilage
- apply pressure and ask patient to take a deep breath
- cause liver and gallbladder to descend and press against your finger
What conditions is Murphy’s sign super painful in?
cholecystitis
What would peritonitis show up as in examination with RUQ pain?
- lie still
- rigid and tender abdomen and guarding
- may be no bowel sounds
What are signs of SBO?
- distended abdomen
- absent or tinkling bowel sounds
- if bowel becomes strangulated signs of peritonitis would predominate
What blood tests are essential in RUQ pain
- FBC
- LFTs
- Bilirubin
- Serum lipase and amylase
What do you look for and why in FBC?
- Anaemia if chronic bleeding from ulcer
2. WCC high if inflammatory condition
What condition is serum lipase and amylase very high?
pancreatitis
What conditions is serum lipase and amylase slightly high in?
- bowel obstruction
- mesenteric ischaemia
- posteriorly perforated duodenal ulcer
- mumps
- pancreatic carcinoma
- opiate medication
What does raised AST and ALT suggest?
damage to hepatocytes
What does rasied ALP and GGT suggest?
obstruction of CBD
What does elevated levels of unconjugated bilirubin suggest?
heamolytic anaemia, Gilberts syndrome - liver cannot conjugate bilirubin fast enough
What does elevated levels of conjugated bilirubin suggest?
(liver working fine) - obstruction of bile flow in liver or outside of liver
What imaging do you do for RUQ?
- CXR
- US of pancreas CBD and gallbladder
- AXR
What do you look for in CXR and RUQ?
- Air under diaphgram suggest a perforated viscus e.g. gastric or duodenal ulcer
- Wide mediastinum and/or heart shadow; suggest aortic dissection
What do you look for in US of RUQ pain?
- Thickened inflamed wall of gallbladder: cholecystits
2. Look for presenece/absence of gallstones, biliary sludge and presence of intra or extrahepatic duct dilation
What do you look for in AXR for RUQ pain?
bowel obstruction or perforation: look for Rigler’s sign
What is cholecystitis?
inflammation of gallbladder
Why does pain for cholecystitis start as poorly localised?
Irritation of virsceral peritoneum in initial stages produced poorly localised midline epigastirc pain
When does the pain in cholecystitis go into RUQ?
As irritation spreads outwards to parietal peritoneum pain becomes sharply localized to RUQ
What can the inflammaed gallbladder irritate?
liver scapisle and diaphragm above it - referred pain to shoulder (right scapula) (C3,C4, C5)
What sort of pain does cholecystitis cause?
Inflammed gallbladder irritates parietal perineum causing constant pain
What is the initial management for cholecystitis?
- ABC
- History
- Full examination
- First line investigation
- Diagnosis
What is the non-operative treatment of cholecystitis?
- Clear fluids
- IV fluids: to avoid or treat dehydration
- Analgesia
- Antibiotic
What is the operative treatment of cholecystitis?
laparoscopic cholecystectomy
