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