Right Upper Quadrant Pain

The patient is complaining of RUQ pain and you cannot just give him or her a bag of pills and send him or her home. The patient’s condition may be serious. However, you are in a hurry to get out of the office because you have another important appointment. What do you do? The key is to visualize the anatomy. Imagine the liver, gallbladder, bile ducts, hepatic flexure of the colon, duodenum, and head of the pancreas. Surrounding these are the skin, fascia, ribs, and thoracic and lumbar spine, with the intercostal nerves and arteries and abdominal muscle. Pain is usually from inflammation, trauma, or infarction. The patient gives no history of trauma, but he or she could have a contusion of the muscle from coughing hard. That is not likely, however, unless the patient has other symptoms of the respiratory tract. The possible sources of inflammation should be narrowed down first. The liver can be inflamed from hepatitis (most likely viral), the gallbladder from cholecystitis (most likely induced by stones and bacteria), or the bile ducts from cholangitis. The colon may be involved with diverticulitis, a segment of granulomatous colitis, or perhaps there is a retrocecal appendix. The duodenum, of course, would most likely have a peptic ulcer which could cause an obstruction or a perforation if the patient is vomiting, or pallor and shock if the patient is bleeding. The pancreas could be inflamed with pancreatitis, especially if the patient drinks alcohol. These are the most important intra-abdominal considerations, but if the mnemonic VINDICATE in Table 7 were applied one might not forget the Budd–Chiari syndrome (thrombosis of the hepatic veins), portal vein thrombosis, or pyelophlebitis; these are rare. In addition, toxic hepatitis from isoniazid, thorazine, and erythromycin estolate (Ilosone), for example, can be painful. Collagen diseases affecting the liver are another possibility. Now let us round out the differential with extra-abdominal disorders. The skin may be involved with herpes zoster or cellulitis. A fascial rent may cause a hernia, particularly if there was previous upper abdominal surgery. Compression of the nerve roots by a herniated disc, thoracic spondylosis, or a spinal cord tumor is possible, but unlikely. Systemic conditions, such as lead colic and porphyria, and involvement of another organ, such as the kidney, must be considered (pyelonephritis or renal colic).

Approach to the Diagnosis

As in the case of generalized abdominal pain, an immediate CBC, urinalysis, chemistry profile, serum amylase and lipase levels, and flat plate and upright films of the abdomen are ordered. If cholecystitis is suspected, ultrasonography or nuclear scanning of the gallbladder (hepatoiminodiacetic acid [HIDA] scan) is ordered. If there is jaundice, a common duct stone can be ruled out by endoscopic retrograde cholangiopancreatography (ERCP).

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RIGHT UPPER QUADRANT PAIN

	V	I	N	D
	Vascular	Inflammatory	Neoplasm	Degenerative
Skin		Herpes zoster Cellulitis
Muscle and Fascia		Diaphragmatic abscess Trichinosis
Liver	Infarct Pyelophlebitis	Hepatitis Hepatic abscess	Carcinoma
Gallbladder		Cholecystitis Cholangitis	Cholangioma
Duodenum	Mesenteric thrombosis	Ulcer Duodenitis
Colon		Diverticulitis Colitis
Pancreas		Pancreatitis	Pancreatic carcinoma
Lymph Nodes		Mesenteric adenitis	Hodgkin lymphoma Lymphosarcoma
Adrenal Gland	Adrenal infarct	Waterhouse–Friderichsen syndrome Tuberculosis	Neuroblastoma Adrenal carcinoma
Kidney	Occlusion Embolism Renal vein thrombosis	Pyelonephritis
Thoracic Spine		Tuberculosis Osteomyelitis	Primary, metastatic, multiple myeloma	Osteoarthritis
Referred	See Table 11

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Other Useful Tests

1. Surgery consult
2. CT scan of the abdomen
3. Quantitative urine amylase
4. Urine porphobilinogen (porphyria)
5. Gallium scan (subphrenic abscess)
6. IVP (renal stone)
7. Liver function studies (common duct stone)
8. Blood lead level
9. Pregnancy test (ruptured ectopic pregnancy)
10. X-ray of thoracolumbar spine (radiculopathy)
11. Laparoscopy (ruptured viscus)
12. Aortogram (dissecting aneurysm)
13. Lymphangiogram (Hodgkin lymphoma)
14. Exploratory laparotomy

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RIGHT LOWER QUADRANT PAIN

	I	C	A	T	E
	Intoxication or	Congenital or	Autoimmune	Trauma	Endocrine	Foreign
	Idiopathic	Acquired Anomaly	or Allergic			Body
		Ventral hernia Incisional hernia		Contusion Cough Hemorrhage
	Alcoholic hepatitis			Contusion Laceration
				Traumatic rupture		Calculus
	Ulcer	Diverticulum Obstruction
		Diverticulum Obstruction
		Cyst				Calculus
	Gout	Hydronephrosis		Contusion Laceration	Hyperparathyroidism	Calculus
			Rheumatoid spondylitis	Herniated disc Fracture

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Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Upper back pain: Introduction (review 20 causes)
• Next Book Extract About Upper back pain: Consider the differential diagnosis oflow back pain in pre-teens, which may include oncologic diagnoses and infections that cause pain prior tobecoming clinically identifiable in diagnostic studies (Avoiding Common Pediatric Errors)
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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

 » Next page: Consider the differential diagnosis oflow back pain in pre-teens, which may include oncologic diagnoses and infections that cause pain prior tobecoming clinically identifiable in diagnostic studies (Avoiding Common Pediatric Errors)

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