RUQ pain Flashcards
What are the ddx for RUQ pain
Biliary colic Cholecystitis* Duodenal ulcer Pancreatitis* Basal pneumonia irritating Rt hemidiaphragm Ascending cholangitis* Gastric Ulcer Small bowel obstruction* Appendicitis* Pyelonephritis* Hepatitis
In elderly patients, the likelihood of which conditions increases
Pneumonia, cancer, vascular disease
What questions about HPC should be asked
- Any other symptoms? - fever = infective process, not MI. Weight loss = ?Ca
- When did they last open bowels and any flatus? - if they can’t even pass wind (absolute constipation) = surgical emergency (obstruction)
- Any change in stool? - Steatorrhoea indicates CBD obstruction. If malaena present, then indicates bleeding ulcer or blood entering bowel
- Is pt female/pregnant - ?pre eclampsia, cholestasis of pregnancy
On examination of someone with RUQ pain, what should you look for
- Jaundice - could indicate gallstones in CBD, ascending cholangitis, acute pancreatitis, pancreatic cancer, cholangiocarcinoma
- Bruising/discolouration of umbilicus/flank = ?severe pancreatitis
- Pulsatile and laterally expansile central mass = AAA
- Murphy sign - if patient arrests inspiration as GB strikes fingers then this indicates cholecystitis (inflamed GB)
- Peritonitis - rigid and motionless and guarding. Suggest peptic ulcer perforation or GB perforation
- Distended abdomen / absent or tinkling bowel sounds - signs of small bowel obstruction
Which blood tests should be done in a patient with RUQ pain
- FBC - anaemia could be due to gastric/duodenal ulcer. High WCC if cholecystitis/ascending cholangitis/basal pneumonia
- Serum amylase/lipase - Very high amylase or lipase indicates pancreatitis. High amylase/lipase may be pancreatitis (common) but also can be bowel obstruction/mesenteric ischaemia, duodenal ulcer, mumps/cancer
- Liver enzymes - high AST/ALT = liver inflammation (hepatitis/obstruction of CBD due to gallstone/infection or tumour of CBD/pancreas). Raised ALP and GGT = obstruction of CBD
- Bilirubin - high unconjugated bilirubin = haemolytic anaemia or Gilberts syndrome. High conjugated bilirubin = obstruction of bile flow - primary biliary cirrhosis with intrahepatic scarring or gallstones blocking CBD
What imaging will you do to investigate?
- Erect CXR - air under diaphragm = perforated viscus (e.g. gastric or duodenal ulcer). Wide mediastinum = aortic dissection
- USS of pancreas, CBD and GB - thickened GB wall = cholecystitis. Look for dilatation too.
- AXR - if suspicious about bowel obstruction or perforation (Riglers sign)
Middle aged, caucasian woman with RUQ pain. She has positive Murphys sign, fever and previous hx of pain in this area after heavy, fatty meals. Shoulder pain also commonly stated. What is likely diagnosis
Cholecystitis
What is the most common cause of cholecystitis
Stone in GB
E. coli and enterococcus are gram ____?
Negative
After conservative management, what measures are taken?
Laparoscopic cholecystectomy to remove inflamed GB
What is empyema and what is it a complication of?
Empyema = pus collection in GB that requires drainage
It is a common complication of cholecystitis. Another common complication is cholecystoduodenal fistula (fistula which joins GB and small bowel - allows gallstones to travel into small bowel and can cause gallstone ileus or GB cancer).
What is Charcots triad and what is it diagnostic of?
Charcots triad = RUQ pain, jaundice, fever with rigors
Charcots triad indicates ascending cholangitis
Briefly describe ascending cholangitis
Inflammation of CBD due to infected stone in CBD or spread of an infected GB (cholecystitis).
It causes jaundice as CBD inflammation causes it to become obstructed so conjugated bilirubin builds up
How is ascending cholangitis managed?
Surgical emergency.
Management includes blood cultures, Abx, ERCP drainage or PTC if ERCP fails, monitoring, definitive management
Patient has sharp stabbing pains that come on a few hours after a fatty meal. Pain comes and goes over several hours but is self limiting. What is the diagnosis
Biliary colic due to cholelithiasis (gallstones).
If stone irritates Hartmanns pouch (where GB meets cystic duct) it can cause sharp stabbing pain.
Surgically remove stone via ERCP
