Right Upper Quadrant
(ruq) Abdominal Pain
Presentation and evaluation
The evaluation of a patient with right upper quadrant abdominal pain begins with a
careful history and physical. Noting the character, location, duration, radiation, and
intensity of symptoms as well as aggravating, alleviating, and associated findings will
lead to a reasonable differential diagnosis. For example, RUQ pain that is post-prandial,
that begins 30 minutes after a meal and lasts for 2 hours, radiates around the back, is
dull in nature, and abates spontaneously is most likely biliary colic due to
gallstones.
Symptoms associated with acute cholecystitis are usually more acute and
persistent. The patient may have a history of biliary colic, with the pain starting in the
epigastrium, associated bloating or belching. Subsequently, the pain may worsen and
radiate to the right upper quadrant. Patients may confuse these symptoms with heartburn.
Pertinent history can include use of antacids without relief of symptoms. There also may
be an associated fever. On palpation of the RUQ a premature inspiratory pause may be noted
(Murphys sign). A palpable gallbladder with jaundice may indicate chronic
bile duct obstruction from tumor and may not have much associated pain (painless
jaundice). Occasionally a point of maximal tenderness may be in the RLQ or more
epigastric depending on the anatomy of the patient. An elevated pulse rate or temperature
may also go along with acute cholecystitis.
Laboratory studies
Laboratory studies to assist in narrowing the differential diagnosis will include a CBC, chem 20 including an AST, ALT, bilirubin, alkaline
phosphatase, amylase, and urinalysis. A chest x-ray may also be helpful in identifying lower lobe pneumonia or
finding free air under the diaphragm. An elevated WBC, increased temperature, and RUQ
tenderness may indicate cholangitis (purulent fluid/pus in common bile duct). This will
necessitate urgent antibiotics and possible early bile duct decompression by a surgical or
endoscopic means. There may be some mild liver function test elevations and a significant
alkaline phosphatase elevation. An elevated amylase suggests pancreatitis; etiology may be
idiopathic or from gallstones, alcohol, or drug use. An elevated WBC and persistent RUQ
pain and/or tenderness with normal LFTs usually leads to the diagnosis of acute
cholecystitis. An ultrasound can be helpful in the diagnostic work up because it may show
gallbladder wall thickening or pericholecystic fluid. The nuclear medicine HIDA scan is
most definitive test to confirm acute cholecystitis.
Treatment of cholecystitis
The initial treatment of acute cholecystitis involves keeping the patient NPO, IV
antibiotics and fluid replacement. If the diagnosis can be made with confidence or
confirmed with another study, parenteral narcotics may be used for pain control.
Meperidine is preferred over morphine because it tends to cause less sphincter of Oddi
contraction. Monitor vital signs and urine output. Patients begin to notice an improvement
within a few hours and are significantly better in 12-18 hours. Patients that look worse
and have an increasing WBC should be re-evaluated for other possible causes or a failure
of initial non-operative management. Consider as an urgent Medevac for early surgical
care. The majority of acute cholecystitis patients will respond to IV antibiotics.
Cholecystectomy can be delayed 24-72 hours. If this is not available, initial
non-operative treatment with 5-7 days of antibiotic therapy followed by elective
cholecystectomy in 6 weeks is acceptable, although there is a 10-20 percent recurrence
rate of symptoms in the convalescence period.
Treatment of Pancreatitis
Initial treatment of pancreatitis should include placing the patient in a NPO status,
establishment of IV hydration, and nasogastric tube suctioning for multiple episodes of
emesis or evidence of an ileus on abdominal x-rays. Patients should respond in 12 hours.
Intravenous
Meperidine may be used sparingly to get initial pain control. Therapy should
be continued until pain, ileus, and hyperamylasemia resolve.
Ransons Criteria for Predicting
Severity of Acute Pancreatitis
On admission
Blood Glucose > 200mg/dl
Lactate dehydrogenase > 350 IU/L
Aspartate transaminase >250 U/L
Within 48 hours
-
BUN >5mg/dl
-
Pa02 <60mmHg
-
Serum
calcium <8mg/dl
-
Decrease in HCT >10%
-
Base deficit >4mEq/L
-
Fluid sequestration > 6L
Patients with more than 2 of Ransons criteria should be considered for early
medevac as well as patients that get progressively worse or have significant ileus.
Treatment of Acute Cholangitis
Acute cholangitis can be initially managed with IV antibiotics (usually a second or
third generation cephalosporin to cover predominantly gram negative organisms). The
patient should be evaluated further to determine the etiology of the cholangitis (i.e.,
choledocholithiasis). This may be done with a variety of tools including ultrasound, ERCP,
and/or CT scanning. Any patient with acute cholangitis that deteriorates or does not
rapidly respond to antibiotic therapy should be evacuated as soon as safely possible.
Reference
-
Sabiston DC, Textbook of Surgery, 15th edition, p. 1161.
Prepared by LCDR Afzal H. Abdullah, MC, USN, General Surgeon, Fleet Surgical Team
Two and Staff Surgeon, Portsmouth, VA (1999).
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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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