Right Upper Quadrant Pain

Question 1

What are RUQ pain differentials for a youngish person gastro?

Answer 1

1. Biliary colic
2. Cholecystitis
3. Duodenal cancer
4. Pancreatitis
5. Ascending cholangitis
6. Gastric ulcer
7. SBO
8. Appendicitis
9. Hepatitis
10. Fitz-hugh-curtis syndrome

Question 2

What are RUQ pain differentials for a youngish person non gastro?

Answer 2

1. Basal pneumonia

2. Pyelonephritis

Question 3

What questions do you need to ask about RUQ?

Answer 3

1. Socrates

2. Symptoms other than pain e.g. fever, weight loss

Question 4

What assoicated symptoms questions do you ask about and why?

Answer 4

1. Last open their bowel or pass any flatus - absolute constipation obstruction
2. Any change in stool recently - CBD obstructed (steatorrhea), Bleeding ulcer (melaena)
3. Pregnancy - ectopic?

Question 5

What signs do you look for on examination of RUQ pain?

Answer 5

1. Jaundice
2. Cullens or Greys sign
3. Pulsatile laterally expansive central mass
4. Murphy’s sign
5. Peritonitis
6. Signs of SBO

Question 6

What would jaundice with RUQ pain suggest?

Answer 6

1. choledocholithiasis
2. asceding cholangitis
3. acute pancreatitis
4. pancreatic cancer
5. cholagiocarinoma

Question 7

What would cullen’s or grey turner’s sign with RUQ pain suggest?

Answer 7

acute haemorrhagic pancreatitis

Question 8

What would a pulsatile laterally expansive central mass with RUQ pain suggest?

Answer 8

AAA

Question 9

What is Murphy’s sign?

Answer 9

1. palpate abdomen just below tip of right ninth costal cartilage
2. apply pressure and ask patient to take a deep breath
3. cause liver and gallbladder to descend and press against your finger

Question 10

What conditions is Murphy’s sign super painful in?

Answer 10

cholecystitis

Question 11

What would peritonitis show up as in examination with RUQ pain?

Answer 11

1. lie still
2. rigid and tender abdomen and guarding
3. may be no bowel sounds

Question 12

What are signs of SBO?

Answer 12

1. distended abdomen
2. absent or tinkling bowel sounds
3. if bowel becomes strangulated signs of peritonitis would predominate

Question 13

What blood tests are essential in RUQ pain

Answer 13

1. FBC
2. LFTs
3. Bilirubin
4. Serum lipase and amylase

Question 14

What do you look for and why in FBC?

Answer 14

1. Anaemia if chronic bleeding from ulcer

2. WCC high if inflammatory condition

Question 15

What condition is serum lipase and amylase very high?

Answer 15

pancreatitis

Question 16

What conditions is serum lipase and amylase slightly high in?

Answer 16

1. bowel obstruction
2. mesenteric ischaemia
3. posteriorly perforated duodenal ulcer
4. mumps
5. pancreatic carcinoma
6. opiate medication

Question 17

What does raised AST and ALT suggest?

Answer 17

damage to hepatocytes

Question 18

What does rasied ALP and GGT suggest?

Answer 18

obstruction of CBD

Question 19

What does elevated levels of unconjugated bilirubin suggest?

Answer 19

heamolytic anaemia, Gilberts syndrome - liver cannot conjugate bilirubin fast enough

Question 20

What does elevated levels of conjugated bilirubin suggest?

Answer 20

(liver working fine) - obstruction of bile flow in liver or outside of liver

Question 21

What imaging do you do for RUQ?

Answer 21

1. CXR
2. US of pancreas CBD and gallbladder
3. AXR

Question 22

What do you look for in CXR and RUQ?

Answer 22

1. Air under diaphgram suggest a perforated viscus e.g. gastric or duodenal ulcer
2. Wide mediastinum and/or heart shadow; suggest aortic dissection

Question 23

What do you look for in US of RUQ pain?

Answer 23

1. Thickened inflamed wall of gallbladder: cholecystits

2. Look for presenece/absence of gallstones, biliary sludge and presence of intra or extrahepatic duct dilation

Question 24

What do you look for in AXR for RUQ pain?

Answer 24

bowel obstruction or perforation: look for Rigler’s sign

Question 25

What is cholecystitis?

Answer 25

inflammation of gallbladder

Question 26

Why does pain for cholecystitis start as poorly localised?

Answer 26

Irritation of virsceral peritoneum in initial stages produced poorly localised midline epigastirc pain

Question 27

When does the pain in cholecystitis go into RUQ?

Answer 27

As irritation spreads outwards to parietal peritoneum pain becomes sharply localized to RUQ

Question 28

What can the inflammaed gallbladder irritate?

Answer 28

liver scapisle and diaphragm above it - referred pain to shoulder (right scapula) (C3,C4, C5)

Question 29

What sort of pain does cholecystitis cause?

Answer 29

Inflammed gallbladder irritates parietal perineum causing constant pain

Question 30

What is the initial management for cholecystitis?

Answer 30

1. ABC 2. History 3. Full examination 4. First line investigation 5. Diagnosis

Question 31

What is the non-operative treatment of cholecystitis?

Answer 31

1. Clear fluids 2. IV fluids: to avoid or treat dehydration 3. Analgesia 4. Antibiotic

Question 32

What is the operative treatment of cholecystitis?

Answer 32

laparoscopic cholecystectomy