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the patient with acute RUQ pain in ED

read this first: abdominal pain in ED

right upper quadrant pain:

differential diagnosis:


  • differential diagnosis:
      • 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 EOU if no complications such as pancreatitis
      • 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;
      • 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)
    • 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
      • 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)

other intra-abdominal causes of RUQ pain:

extra-abdominal causes of RUQ pain:

initial Mx of RUQ pain in ED:

  • all patients with abnormal LFT's or who are possible cholecystitis or pancreatitis should be referred for an urgent gen surg registrar consult
  • 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
abdopain_ruq.txt · Last modified: 2022/08/05 07:00 by gary1

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