RUQ pain (oxford clin cases)

Question 1

What are some differentials when someone presents with RUQ pain?

Answer 1

Cholecytsitis
Biliary colic 
Duodenal ulcer
Pancreatitis 
Ascending cholangitis 
Small bowel obstruction
Pyelonephritis

Question 2

What differential for RUQ pain are more likely if someone is older?

Answer 2

Cancer
Pneumonia
Vascular disease like aortic dissection, aortic aneurysm etc

Question 3

What does fever alongside RUQ pain suggest?

Answer 3

Infection

Question 4

When is it an emergency if a patient complains of not having bowel movements?

Answer 4

If they aren’t having bowel movements they might just be constipated but if they are not even passing any flatus, there may be a surgical emergency

Question 5

What will happen to stools if there is obstruction of the bile duct? Explain the pathophysiology and also how patients will describe it

Answer 5

Steatorrhea- the stool will be pale, it will float and it will be smelly
This occurs because bile cannot get into the large intestine and facilitate the break down of fats, bilirubin is also not broken down into urobilinogen or stercobilinogen by gut bacteria and stercobilinogen gives feaces their brown colour

Question 6

What will happen to stool if there is an ulcer?

Answer 6

There will be melaena- the stool will be very dark in colour and smelly

Question 7

What character is the blood when someone has melaena?

Answer 7

Oxidised

Question 8

What do you need to exclude when a female comes in with RUQ pain?

Answer 8

Pregnancy

Question 9

In what conditions is jaundice seen?

Answer 9

Gallstones
Pancreatitis
Pancreatic tumor
Ascending cholangitis
Cholangiocarcinoma

Question 10

What signs are characteristically seen in pancreatitis? Describe what you would see

Answer 10

Grey-Turner’s sign and Cullen’s sign= bruising around the flank and umbilicus

Question 11

What is Murphy’s sign?

Answer 11

When you palpate under the ninth costal cartilage and the patient experiences sharp pain on inhalation as an enlarged gallbladder or pancreas strikes your hand while moving down

Question 12

What differentials of RUQ pain will cause peritionitis?

Answer 12

Perforation of the gallbladder or peptic ulcer

Question 13

What will a patient with peritonitis look like/experience?

Answer 13

They will lie very still and there will be guarding when you try to examine them

Question 14

What are some signs of small bowel obstruction?

Answer 14

Distended abdomen
Absent bowel sounds or bowel sounds that are tinkling
Peritonitis if there is stangulation

Question 15

Why would you do an FBC when someone presents with RUQ pain?

Answer 15

To check for anaemia- this may be present if there is a chronic bleeding ulcer
To check WCC, if raised this suggests inflammation

Question 16

Why would you do serum amylase/lipase when someone presents with RUQ pain?

Answer 16

To check for pancreatic pathology

Question 17

What does a slightly raised amylase suggest in someone with RUQ pain?

Answer 17

Many pathologies are possible eg pancreatic, bowel obstruction, mesenteric ischaemia, ulcers, carcinoma etc

Question 18

What does a highly raised amylase/lipase suggest in someone with RUQ pain?

Answer 18

Pancreatic pathology

Question 19

What does a high AST and ALT in LFTs suggest when someone has RUQ pain?

Answer 19

Damage to hepatocytes- possible due to hepatitis or obstruction of the bile duct from gallstones

Question 20

What does a high ALP by itself in LFTs suggest?

Answer 20

Increased bone breakdown eg Paget’s disease

Question 21

What does high ALP with high AST/ALT or with high GGT suggest?

Answer 21

Obstruction of the common bile duct

Question 22

If you saw high AST/ALT with a higher ALP what diagnosis is likely?

Answer 22

Some sort of obstruction of the bile duct

Question 23

If you saw high AST/ALT with a higher ALP and high GGT what diagnosis is likely?

Answer 23

Some sort of obstruction of the bile duct

Question 24

What pathologically does a high unconjugated bilirubin suggest?

Answer 24

Excess breakdown of RBCs or inability to conjugate due to enzyme deficiency (genetic)

Question 25

What pathologically does a high conjugated bilirubin suggest?

Answer 25

Problems with outflow of bile from liver

Question 26

What should you always do before radiographing a woman?

Answer 26

A pregnancy test if she is fertile

Question 27

What imaging might you do if someone present with RUQ pain and when?

Answer 27

Erect chest radiograph- to look for cardiac pathology or if you suspect bowel obstruction etc
Abdominal radiograph- not usually first line, most gallstones would not show up but if you suspect bowel obstruction maybe a good idea
Ultrasound of pancreas, bile duct and gallbladder

Question 28

Where apart from the RUQ will pain from the gallbladder be? Why?

Answer 28

Right scapula- the diaphragm is supplied by C3, 4 and 5 which also supplies the scapula so when the gallbladder becomes inflamed and iritates the right hemidiagphragm the signal gets mixed and pain is felt in the right scapula too

Question 29

What supportive treatments will you give someone who presents with acute cholecystitis and explain why

Answer 29

IV fluids- if they have been vomiting they will be dehydrated
Analgesia- not orally if someone is vomiting
Antibiotics- to combat infection before surgery