the patient with acute RUQ pain in ED

read this first: abdominal pain in ED

• see also: liver function tests (LFTs)
• differential diagnosis:
  • biliary colic:
    • acute onset severe RUQ pain, usually going through to R scapula
    • WCC should be normal; LFT's are usually normal;
    • US should show gallstones.
    • consider admit to SSU if no complications such as pancreatitis
    • all symptomatic patients with biliary disease (and those with gallstones > 2cm) should be referred to gen surg
      • gallbladder polyps should be referred to surg OP
      • asymptomatic gallstones < 2cm can be referred to GP Mx
  • cholecystitis:
    • WCC and may be normal and liver function tests (LFTs) are usually normal
    • presence of stones, a thickened GB wall, GB distension, pericholecystic fluid & +ve sonographic Murphy's sign has >90% PPV for cholecystitis
    • the absence of stones & a normal GB on US makes the Dx of cholecystitis very unlikely, although a large, tense, static GB without stones, particulary in unwell hospitalised patients may represent acalculous cholecystitis which has a high mortality and morbidity.
    • pts with cholecystitis should be discussed with surg. reg. for probable admission
  • gallbladder empyema:
    • life-threatening emergency resulting from complete obstruction of the cystic duct with sepsis
    • presents similar to ascending cholangitis
    • urgent cholecystectomy after IV fluid resus. & Iv anti's;
  • gallbladder gangrene / emphysematous cholecystitis:
    • life-threatening complication of 1% cholecystitis resulting from cystic duct obstruction causing ischaemic necrosis
    • usually diabetic men and 30% are acalculous
    • suspect if see air in the GB, the GB wall or biliary tree; Mx as for GB empyema;
  • ascending cholangitis:
    • life-threatening emergency resulting from complete biliary obstruction (usually CBD) with sepsis
    • classic Charcot triad of fever, jaundice & RUQ pain only present in 25%
    • suspect in all elderly patients with sepsis, and those with epigastric/RUQ pain, abnormal LFTs and fever, even if they have had a cholecystectomy as CBD obstruction can be from retained stones, primary CBD stones or strictures.
    • WCC is usually raised, but maybe normal, or even leukopenic if septic.
    • >88% have raised serum bilirubin; and ~78% have raised alkaline phospatase; ALT/AST are often mildly raised.
    • Mx:
      • FBE, U&E, LFTs, amylase, lipase, coagulation profile, Xmatch, 2 sets of blood cultures
      • biliary US to see if CBD is dilated, +/- CT abdo.
      • IV fluid resus;
      • broad-spectrum IV anti's, vitamin K, +/- NGT, +/- inotropic support and early decompression
  • Mirizzi syndrome:
    • a gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct and raised liver function tests (LFTs)
  • choledocholithiasis
    • even patients with PH cholecystectomy may present with gallstones in CBD resulting in raised liver function tests (LFTs) and biliary colic, with risk of developing ascending cholangitis
  • post-cholecystectomy syndrome
    • occurs in 5-40% of patients
    • 50% of cases are due to biliary causes such as remaining stone, biliary injury, dysmotility and choledococyst.
    • persistent RUQ pains thought to be due to sphincter of Oddi dysfunction or to post-surgical adhesions
    • anorexia, nausea and vomiting
    • bloating and diarrhoea (can be treated with cholestyramine)
  • functional gallbladder disorder:
    • biliary pain resulting from a primary gallbladder motility disturbance in the absence of gallstones or other gallbladder pathology and with a normal biliary USS and normal liver function tests (LFTs)
    • said to occur in 20% women and 8% men with “biliary colic” and normal USS and is a diagnosis of exclusion
    • may benefit from cholecystectomy
  • hepatitis
    • suspect if LFT's are significantly abnormal and not of an obstructive picture
    • viral hepatitis, alcoholic, drug/toxic, etc.
    • Fitz Hugh-Curtis syndrome (gonococcal or chlamydial perihepatitis) - rare
  • liver abscess (rare):
    • pyogenic (usually E.coli, Klebsiella, Proteus, Pseudomonas, Strept. milleri or anaerobes) :
      • aetiology:
        • idiopathic - ? due to oral flora in pts with severe periodontal disease
        • local spread from cholecystitis, ascending cholangitis, ERCP, post-op, etc.
        • bacteraemia from abdominal conditions eg. diverticulitis, appendicitis, perforated or penetrating PU, GIT malignancy, inflammatory bowel disease, peritonitis
        • occasionally may be the presentation of a hepatocellular Ca or GB Ca
        • rarely, from SBE
      • presentation:
        • often sub-acute, insidious, malaise, low grade fever, LOW, dull abdo. pain, RUQ tenderness
        • jaundice is only present late or in presence of ascending cholangitis
      • Ix: anaemia, raised WCC, raised ESR, abn. LFT's esp. raised alk. phosphatase
        • US can detect abscesses as small as 1cm and like CT has sensitivity approaching 100%
      • outcome:
        • 8% mortality with treatment;
        • worse outcomes with delayed diagnosis, multiple organisms, fungal cause, jaundice, low albumin, pleural effusion, underlying biliary malignancy, comorbidities.
      • complications include:
        • empyema; pleuropericardial effusion; portal or splenic vein thrombosis
        • rupture into pericardium; thoracic & abdominal fistula formation; sepsis;
    • amoebic hepatic abscess:
      • aetiology:
        • Entamoeba histolytica (via oral route)
      • presentation:
        • usually more acute than pyogenic, most have symptoms for 2wks
        • some may have latency of many years from preceding amoebic dysentery
      • Ix: 
        • US - cannot differentiate from pyogenic, but amoebic are usually solitary and in right lobe near the diaphragm.
        • serology
  • acute portal vein thrombosis (rare):
    • typically occurs in patients with cirrhosis, pancreatitis, or prothrombotic disorders
    • presence of spiking fevers, chills, and a painful liver in absence of other causes is suggestive of septic PVT (acute pylephlebitis)

• acute pyelonephritis
• pancreatitis (usually epigastric)
• perforated duodenal ulcer
• high retrocaecal appendicitis or appendicitis in late pregnancy
• renal colic
• renal infarct / infarction
• renal artery aneurysm rupture (rare)
• traumatic liver haematoma
• free intraperitoneal fluid or gas (usually will also cause R shoulder tip pain):
• post-laparoscopy
• ruptured ectopic pregnancy
• peritonitis
• mesenteric panniculitis (MP) / sclerosing mesenteritis

• RLL pneumonia
• pleural effusion / pleurisy / PE / AMI
• musculoskeletal
• herpes zoster (shingles)
• radicular pain from a thoracic spine issue such as discitis, osteomyelitis, tuberculosis (TB), crush fracture
  • may be bilateral!

• IV morphine and IV fluids if needed
• FBE, U&E, LFTs, lipase, CRP
• FWT urine to exclude pyelonephritis
• exclude pregnancy
• EXAMINE the patient
  • is there an abdominal aortic aneurysm (AAA) or an abdominal mass?
  • RUQ tenderness? Murphy sign? are you really sure it is not primary RIF or flank pain?
  • is there peritonism?
  • are bowel sounds normal?
  • are there signs of zoster
  • is there thoracic spinal tenderness or suggestion of pneumonia
• consider erect CXR to exclude pneumonia, etc as well as perforated viscus
• consider abdo. US or abdo CT - same day if unwell or raised WCC with no clear cause
• if biliary colic, consider admission to ED observation unit and ensure gen. surgery follow up as outpatient or privately via GP