RUQ pain (oxford clin cases) Flashcards
What are some differentials when someone presents with RUQ pain?
Cholecytsitis Biliary colic Duodenal ulcer Pancreatitis Ascending cholangitis Small bowel obstruction Pyelonephritis
What differential for RUQ pain are more likely if someone is older?
Cancer
Pneumonia
Vascular disease like aortic dissection, aortic aneurysm etc
What does fever alongside RUQ pain suggest?
Infection
When is it an emergency if a patient complains of not having bowel movements?
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
What will happen to stools if there is obstruction of the bile duct? Explain the pathophysiology and also how patients will describe it
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
What will happen to stool if there is an ulcer?
There will be melaena- the stool will be very dark in colour and smelly
What character is the blood when someone has melaena?
Oxidised
What do you need to exclude when a female comes in with RUQ pain?
Pregnancy
In what conditions is jaundice seen?
Gallstones Pancreatitis Pancreatic tumor Ascending cholangitis Cholangiocarcinoma
What signs are characteristically seen in pancreatitis? Describe what you would see
Grey-Turner’s sign and Cullen’s sign= bruising around the flank and umbilicus
What is Murphy’s sign?
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
What differentials of RUQ pain will cause peritionitis?
Perforation of the gallbladder or peptic ulcer
What will a patient with peritonitis look like/experience?
They will lie very still and there will be guarding when you try to examine them
What are some signs of small bowel obstruction?
Distended abdomen
Absent bowel sounds or bowel sounds that are tinkling
Peritonitis if there is stangulation
Why would you do an FBC when someone presents with RUQ pain?
To check for anaemia- this may be present if there is a chronic bleeding ulcer
To check WCC, if raised this suggests inflammation
Why would you do serum amylase/lipase when someone presents with RUQ pain?
To check for pancreatic pathology
What does a slightly raised amylase suggest in someone with RUQ pain?
Many pathologies are possible eg pancreatic, bowel obstruction, mesenteric ischaemia, ulcers, carcinoma etc
What does a highly raised amylase/lipase suggest in someone with RUQ pain?
Pancreatic pathology
What does a high AST and ALT in LFTs suggest when someone has RUQ pain?
Damage to hepatocytes- possible due to hepatitis or obstruction of the bile duct from gallstones
What does a high ALP by itself in LFTs suggest?
Increased bone breakdown eg Paget’s disease
What does high ALP with high AST/ALT or with high GGT suggest?
Obstruction of the common bile duct
If you saw high AST/ALT with a higher ALP what diagnosis is likely?
Some sort of obstruction of the bile duct
If you saw high AST/ALT with a higher ALP and high GGT what diagnosis is likely?
Some sort of obstruction of the bile duct
What pathologically does a high unconjugated bilirubin suggest?
Excess breakdown of RBCs or inability to conjugate due to enzyme deficiency (genetic)
What pathologically does a high conjugated bilirubin suggest?
Problems with outflow of bile from liver
What should you always do before radiographing a woman?
A pregnancy test if she is fertile
What imaging might you do if someone present with RUQ pain and when?
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
Where apart from the RUQ will pain from the gallbladder be? Why?
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
What supportive treatments will you give someone who presents with acute cholecystitis and explain why
IV fluids- if they have been vomiting they will be dehydrated
Analgesia- not orally if someone is vomiting
Antibiotics- to combat infection before surgery
