Right Upper Quadrant Pain Flashcards
List the differential diagnosis for RUQ pain.
Biliary colic Cholecystitis Duodenal ulcer Ascending cholangitis Pancreatitis Basal pneumonia
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.
- 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?
What is steatorrhoea caused by?
Biliary obstruction meaning that bile no longer reaches the duodenum
List two causes of RUQ pain that are exclusive to pregnancy.
Cholestasis of pregnancy
Pre-eclampsia
Why is it important to check whether a patient with RUQ pain could be pregnant?
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)
List some causes of post-hepatic jaundice.
Choledocholithiasis Ascending cholangitis Acute pancreatitis Pancreatic cancer Cholangiocarcinoma
What do Grey Turner’s and Cullen’s sign indicate?
Severe pancreatitis
What is Murphy’s sign?
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
Describe the features of a peritonitic patient on examination.
Still Rigid abdomen that is exquisitely tender Guarding Rebound tenderness There may be no bowel sounds
Describe the signs of bowel obstruction on examination.
Distended abdomen
Tinkling bowel sounds
Signs of peritonitis if the bowel is strangulated or perforated
List some important investigations for patients with RUQ pain.
FBC
Serum amylase/lipase
Liver enzymes (ALT, AST, ALP, GGT and BR)
What can cause a moderate elevation of amylase levels?
Pretty much anything that can go wrong in the abdomen Bowel obstruction Mesenteric ischaemia Pancreatic cancer Opiate medications
What does high AST + ALT indicate?
This is called transminitis
Suggests damage to hepatocytes (e.g. by viral hepatitis, autoimmune hepatitis)
What does high ALP indicate?
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)
What does isolated high GGT indicate?
Alcohol abuse
What can cause unconjugated hyperbilirubinaemia?
Increased bilirubin production (e.g. due to haeomlysis)
Hereditary deficiency of conjugating enzyme (e.g. Gilbert’s syndrome)
What can cause conjugated hyperbilirubinaemia?
Obstruction to bile outflow that is either:
INSIDE the liver (e.g. primary biliary cirrhosis)
OUTSIDE the liver (e.g. choledocholithiasis)
Why may an erect chest X-ray be performed in a patient with RUQ pain?
It may show air under the diaphragm, which would indicate that there is a perforated viscus (e.g. peptic ulcer)
What may be picked up on ultrasound of the pancreas, common bile duct and gallbladder that may indicate the cause of RUQ pain?
Thickened, inflamed gallbladder wall
Dilation of ducts (> 6 mm is abnormal)
What sign may be seen on an abdominal radiograph in a patient with bowel perforation?
Rigler’s sign
This is when air is present on both sides of the intestinal wall – suggests that there has been a perforation
List the five main risk factors for the development of gallstones.
Fat Female Fair Fertile Forty
Describe the different types of pain caused by cholecystitis based on the part of the peritoneum affected.
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
The spread of inflammation to the liver capsule can lead to referred pain to what part of the body?
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
List some complications of cholecystitis.
Gallstone ileus
Empyema
Cholecystoduodenal fistula
Gallbladder carcinoma
List the non-operative steps in the management of a cholecystitis patient.
Only clear fluids by mouth
IV fluids
Analgesia
Antibiotics
What operation will be performed in patients with cholecystitis?
Laparoscopic cholecystectomy
What is Charcot’s triad?
RUQ pain
Jaundice
Fever with rigors
What is ascending cholangitis?
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
Describe the management of ascending cholangitis.
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
What is biliary colic usually caused by?
Cholelithiasis (presence of gallstones in the biliary tract)
What is Hartmann’s pouch?
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)
Describe the symptoms that could result from bleeding peptic ulcers.
Epigastric pain or RUQ pain
Melaena
List some forms of imaging that may be used to investigate bleeding peptic ulcers.
OGD
CT angiogram
Video capsule endoscopy
Red cell scan
