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Yr 3 Oxford Clinical Cases > Right Upper Quadrant Pain > Flashcards

Right Upper Quadrant Pain Flashcards

1
Q

List the differential diagnosis for RUQ pain.

A 
Biliary colic 
Cholecystitis 
Duodenal ulcer 
Ascending cholangitis
Pancreatitis
Basal pneumonia
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2
Q

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.

A
  • 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?
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3
Q

What is steatorrhoea caused by?

A

Biliary obstruction meaning that bile no longer reaches the duodenum

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4
Q

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

A

Cholestasis of pregnancy

Pre-eclampsia

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5
Q

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

A

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)

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6
Q

List some causes of post-hepatic jaundice.

A 
Choledocholithiasis
Ascending cholangitis
Acute pancreatitis 
Pancreatic cancer
Cholangiocarcinoma
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7
Q

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

A

Cullen’s- peri-umbillical bruising
Grey Turner’s- bruising around flank
Severe pancreatitis

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8
Q

How do you check Murphy’s sign and what does it indicate?

A

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

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9
Q

Describe the features of a peritonitic patient on examination. What could cause peritonitis in a patient with RUQ pain?

A 
Still
Rigid abdomen that is exquisitely tender
Guarding 
Rebound tenderness
There may be no bowel sounds
Cause: Perforated peptic ulcer/ gall bladder, stragulated small bowel
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10
Q

Describe the signs of bowel obstruction on examination.

A

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

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11
Q

List some important investigations for patients with RUQ pain.

A

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

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12
Q

What can cause a moderate elevation of amylase levels?

A 
Pretty much anything that can go wrong in the abdomen 
Bowel obstruction
Mesenteric ischaemia 
Pancreatic cancer 
Opiate medications
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13
Q

What does high AST + ALT indicate?

A

This is called transminitis

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

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14
Q

What does high ALP indicate?

A

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)

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15
Q

What does isolated high GGT indicate?

A

Alcohol abuse

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16
Q

What can cause unconjugated hyperbilirubinaemia?

A

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

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

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17
Q

What can cause conjugated hyperbilirubinaemia?

A

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

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18
Q

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

A

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

19
Q

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

A

Thickened, inflamed gallbladder wall

Dilation of ducts (> 6 mm is abnormal)

20
Q

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

A

Rigler’s sign

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

21
Q

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

A 
Fat 
Female 
Fair
Fertile
Forty
FHx
22
Q

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

A

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

23
Q

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

A

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
Boas’ sign

24
Q

List some complications of cholecystitis.

A 
Gallstone ileus
Empyema- collection of pus
Cholecystoduodenal fistula
Gallbladder carcinoma
Ascending cholangitis
25
Q

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

A

Only clear fluids by mouth
IV fluids
Analgesia
Antibiotics

26
Q

What operation will be performed in patients with cholecystitis?

A

Treat cholecystitis then perform Laparoscopic cholecystectomy 6-12 weeks later- less likely to convert to open surgery

27
Q

What is Charcot’s triad?

A

RUQ pain
Jaundice
Fever with rigors

28
Q

What is ascending cholangitis?

A

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

29
Q

Describe the management of ascending cholangitis.

A

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

30
Q

What is biliary colic usually caused by?

A

Cholelithiasis (presence of gallstones in the biliary tract)

31
Q

What is Hartmann’s pouch?

A

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)

32
Q

Describe the symptoms that could result from bleeding peptic ulcers.

A

Epigastric pain or RUQ pain

Melaena

33
Q

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

A

OGD
CT angiogram
Video capsule endoscopy
Red cell scan

34
Q

What is Boas’ sign?

A

RUQ pain radiating to right scapula- indicative of cholecystitis

35
Q

What are the 4 main components of bile?

A

Water
Fat: cholesterol + phospholipids
Bile salts: Emulsify fats + fat soluble vitamins (A,D,E,K)
Conjugated Bilirubin

36
Q

How are bile salts conserved by the body?

A

Enterohepatic recycling- bile salts reabsorbed from the terminal ileum.

37
Q

Both liver disease or a blocked CBD can cause patients to have a prolonged blood clotting time. But administering parenteral Vit K can only problem. Which problem and why?

A

Impaired clotting in CBD obstruction corrected:
Liver disease- impaired synthesis of clotting factors 2,7,9 and 10 –> impaired PT time
CBD obstruction: decreased Vit K absorption –> Vit K dependent reductase doesn’t function leading to reduced clotting factor synthesis+ increased PT

38
Q

Name two main types of gallstones and which groups of patients are prone to them

A
  • Bile pigment stones: Hb breakdown. People with haemolytic anaemias
  • Cholesterol stone: 6Fs. OCPs and Crohn’s sufferers
39
Q

Gallstone complications?

A
  • Biliary colic
  • cholecystitis
  • ascending cholangitis
  • acute pancreatitis
  • cholangeocarcinoma
  • gallbladder cancer
  • gallstone empyema
  • cholecystoduodenal fistula
  • gallstone ileus
40
Q

Which enzyme is released from the duodenum in response to ingestion of fatty foods?

A

Cholecystokinin (CCK)–> gallbladder contraction and bile secretion

41
Q

What is calcot’s triangle?

A

Anatomical zone used to define the path of the cystic artery and the cystic duct. Visualising this helps ensure you cut the cystic duct and ligate cystic artery.

42
Q

What is Mirizzi’s syndrome?

A

A gallstone in Hartmann’s pouch extrinsically presses on the CBD causing obstructive jaundice

43
Q

What is courvoisier’s law?

A

If the gallbladder is palpable in the presence of jaundice, the jaundice is unlikely due to stones (more likely due to tumour)

44
Q

Risks of ERCP

A

Bleeding
Perforation of biliary tree
Cholangitis
Pancreatitis

Yr 3 Oxford Clinical Cases (28 decks)

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