Right upper quadrant pain Flashcards
RUQ differentials for an overweight 38-year-old Caucasian woman who presents to accident and emergency (A&E)
at 11 p.m. complaining of severe pain in the RUQ of her abdomen, nausea, and vomiting.
Biliary colic Acute cholecystitis Duodenal ulcer Pancreatitis Basal pneumonia Ascending cholangitis Gastric ulcer Small bowel obstruction Appendicitis Hepatitis Pyelonephritis Ovarian path
What can cause serum amylase/lipase to rise?
i. slight increase
ii. very large increase
i. slight increases (200–600 U/L) in amylase levels are most commonly caused by pancreatitis, but also by various other pathologies such as: -bowel obstruction, -mesenteric ischaemia, -a posteriorly perforated duodenal ulcer, -mumps, -pancreatic carcinoma, or -opiate medications.
However, very high amylase levels (>1000 U/L) or elevated lipase levels
(>300 U/L) are almost exclusively found in pancreatitis
Imaging for right upper quadrant pain + nausea + vomiting
ERECT CHEST RADIOGRAPH:
air under diaphragm strongly suggests perforated viscus such as gastric ulcer but also after recent surgery. Do a pregnancy test first on a woman of child bearing age even if she insists she cannot be pregnant
What is rigler’s sign
Air on both sides of the bowel wall- suggests perforated gastric or duodenal ulcer.
Loops of bowel are seen on abdo radiograph. What would suggest small/large bowel obstruction
Small bowel loops
with a diameter >3 cm suggests small bowel obstruction (possibly in conjunction with large bowel obstruction). Large bowel loops with a diameter >6 cm
suggests large bowel obstruction.
Not being able to see one of the two shadows caused by both psoas muscles may suggest what
Not being able to see one of the two shadows
caused by both psoas muscles may suggest retroperitoneal fl uid (e.g. a ruptured abdominal aortic aneurysm or pancreatitis)
Normal diameter of common bile duct
Upper limit of normal is 6-7mm
What is classical clinical picture for someone with cholecystitis
a middle-aged,
Caucasian female with RUQ pain, positive Murphy’s sign, fever, and a previous history of pains in this area after heavy, fatty meals. T
Cause of cholecystitis
Cholecystitis (chole = bile, cyst = bladder, -itis = infl ammation) is infl ammation
of the gallbladder, caused in 95% of cases by a stone in the gallbladder. Th e gallbladder has a chemical infl ammation and this may lead to subsequent infection
aff ecting the surrounding tissue.
What causes pain in cholecystits, where is the pain?
The inflamed gallbladder irritates the parietal peritoneum, causing a constant pain. Irritation of the visceral peritoneum in the initial stages produces a poorly localized, dull, midline epigastric pain.
As the irritation spreads outwards to the parietal peritoneum, the pain becomes sharply localized to
the RUQ.
Where else can pain be felt in cholecystitis and why
Th e infl amed gallbladder can also irritate the liver capsule, which in turn
can irritate the diaphragm above it. Th e diaphragm is supplied by nerve roots C3,
C4, and C5 (‘3, 4, 5 keep the diaphragm alive’) which also supply sensation to the
shoulder. Th e referred pain in the right scapula is believed to be because the central
nervous system (probably the dorsal spinal cord, but perhaps the sensory cortex
in the brain) confuses the incoming signals from the right shoulder and the right
hemidiaphragm.
Benefits of doing a lap chole within 72hrs of the cholecystits admission vs 6-12 weeks later
Controversy exists over whether the best
strategy is urgent laparoscopic cholecystectomy within the fi rst 72 hours or
treating the acute episode and then returning the patient for an elective cholecystectomy 6–12 weeks later. Th e arguments in favour of the latter are that
conversion rates from laparoscopic to open surgery are reduced. However,
waiting for an elective procedure may mean that patients have repeat admissions in the interim – and this entails increased morbidity, expense, and lost
time (for the patient).
