RUQ Pain

  • 2 Nov, 2020
  • Reading time:1 mins read
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FieldsGORD Gallstones / Biliary Colic Cholecystitis Ascending Cholangitis GI Bleed Peptic Ulcer Viral Hepatitis 
Age Increases with Age Typically >35 years. Increases with age Typically >40 years Typically >40 years Increases with age Any Age Affected Any 
Gender M = F F > M F > M F > M M > F M > F No predominance 
Typical Presentation An overweight 53 year old man with a 20 pack year smoking history, who drinks ~30 units of alcohol each week presents to his GP with ‘burning’ epigastric pain and an intermittent acidic taste at the back of his throat. He finds it hard to say if the pain is in his chest or epigastrium. He has a history of depression, for which he takes Imipramine. • ‘Female, Fat and Forty’ stereotype An obese 40 year old woman presents with RUQ pain and vomiting. On examination she is restless and sweaty with a BP of 125/90 A woman who is known to have gallstones presents with RUQ pain. On examination, she is icteric with a temperature of 37.8’. Palpation under her costal margin causes her to catch her breath. A 55 year old woman presents with RUQ pain, a fever and jaundice. Her BP is 100/60mmHg and she appears slightly confused. A 65 year old man with a history of peptic ulcer disease visited his GP complaining of several episodes of vomiting blood. He said he felt tired all of the time, and on examination he had pale mucous membranes and was tachycardic and hypotensive A 53 year old man with a 30 pack year smoking history presents to his GP with a 2 month history of epigastric pain which wakes him up at night and is relieved by drinking a glass of milk. It occasionally makes him sick. The pain becomes more severe after evenings at the Pub. A 23 year old student who has recently returned from a trip to North Africa presents with anorexia, nausea, RUQ pain and lethargy. His blood tests show markedly raised ALT. 
Other Symptoms • Frequent ‘heartburn’. Worse after large meals, and at night / om lying down, particularly if soon after eating • Pain relieved by over the counter antacids • Regurgitation of food and acid • Acid brash • Waterbrash • Choking at night • Odynophagia or dysphagia if chronic • Nocturnal asthma/ chronic cough • Pain may be in chest, epigastrium, RUQ or back, or all of these! • Nausea and vomiting in severe attacks Acute: • Fever • Vomiting Chronic: • Nausea • Distension0 • Flatulence • Fat intolerance • IBS• Rigors • Fever • Jaundice • Dark urine • Pale stools • Itchy skin● Tired all the time (if chronic - see Iron Deficiency Anaemia). ● Medical emergency if acute • Vomiting to relieve pain. • Weight loss if chronic. • Tiredness (anaemia) • Duodenal: pain worse at night +/- relieved by eating; Stomach: pain worse with/ just prior to eating.• Fever • Malaise • Upper abdominal discomfort • Jaundice 
Pain • Sudden onset dull/ burning epigastric and retrosternal pain. • Intermittent RUQ/ epigastric pain - "Colicky" • Pain may radiate to right shoulder tip.• Continuous epigastric/ RUQ pain. • Pain radiates to shoulder tip.• Sudden onset RUQ pain often (but not always) associated with Charcot’s triad. Acute or sub-acute • Sudden onset of pain, at first localised to epigastrium, then general if peritonitis. • Pain may radiate to back if the ulcer is posterior.• SX often last 3-6 weeks then subside 
Signs • Laryngitis (hoarse voice) • Overweight • Overweight • Courvoisier’s sign negative• Murphy’s sign positive • Tenderness and muscle guarding on examination• Charcot’s triad (RUQ pain, jaundice, fever) • Reynold's Pentad (RUQ pain, jaundice, fever, hypotension, confusion) • Cholestatic picture● Signs of hypovolaemia/ shock ● Orthostatic hypotension ● Haematemesis/ malaena/ bloody stools ● Pale mucous membranes ● Tachycardia ● Tachypnoea • Abdominal tenderness Peritonitis (if perforated): • Absent bowel sounds • Shock • Shallow breathing (diaphragmatic irritation) • Fever • Tachycardia • >5 Spider naevi if chronic • Jaundice • RUQ tenderness • Mild hepatomegaly; liver diffusely enlarged with firm, sharp, smooth edge. 
Past Medical History • Hiatus Hernia • Smoking • LOS Dysfunction • Alcohol • Fat/ caffeine/ chocolate consumption • ?Stress • Tricyclics/ anticholinergics/ nitrates • Systemic sclerosis • Family HX • Oestrogen • Diet high in fat and low in fibre • Recent rapid weight loss, e.g. following bariatric surgery • Pregnancy • Clofibrate • Contraceptive pill • Pain worse with consumption of fatty foods.• Gallstones previously • Gallstones • Chronic Pancreatitis • HX biliary surgery/ biliary stent • ERCP● DH NSAIDs/ aspirin ● H. Pylori infection ● Hx PUD ● Haemorrhoids ● Ulcerative colitis ● Crohn’s disease ● Dyspepsia ● Liver disease ● Alcoholism • HX of dyspepsia/ GORD • HX of H. Pylori infection • Causes of delayed gastric emptying e.g. neurosurgery/burns • Smoker → reduced prostaglandin synthesis • High alcohol intake • Aspirin/ Steroids/ NSAID use → reduced prostaglandin synthesis • HX Zollinger-Ellison Syndrome • Blood Group O • ?Stress N.B./ Different for different strains of virus • Traveller • IV drug user • Healthworker • Haemophiliac • Haemodyalisis • FH 
Bloods • FBC: May indicate iron-deficiency anaemia • LFTs: High bilirubin, high ALP, slightly raised ALT. • High amylase if stone lodged in last part of CBD → pancreatitis.• FBC: High ESR, high CRP, high WCC • Slightly raised bilirubin, ALP and amino transferase. • High amylase if acute pancreatitis present as complication.• FBC: leucocytosis • Positive blood cultures in 30% (E. Coli, Enterococcus, faecalis, anaerobes) • LFTs: raised bilirubin and alkaline phosphatase● Blood film: normocytic anaemia • FBC: May indicate iron-deficiency anaemia. • U&E: May show Zollinger-Ellison Syndrome• FBC: Lymphocytosis, high ESR, prolonged PT • LFT: High ALT +/- high AST, high bilirubin • Serology: Specific Antbodies/ Antigens permit diagnosis. 
Imaging • Endoscopy: visual identification of inflammation • Barium swallow + water siphon test: may show presence of hiatus hernia or strictures • Radiolabelled technetium shows reflux.• Plain AXR: Shows up 10-15% of cases (if stones are calcified). • USS: 95% specificity – gold standard. • Oral cholecystogaphy • ERCP if no gallstones seen with USS/cholecystography.• USS: Gallstones/ gall bladder wall thickening/ dilated common bile duct >6mm. • MRCP: stones in biliary tree.• US: Dilated CBD +/- cause of obstruction • MRCP: More detail about obstruction● Endoscopy/ colonoscopy will reveal bleed ● CT angiography: reveals exact location of bleed • Endoscopy: visual confirmation of ulcer • Barium meal test: if unable to tolerate endoscopy. • X-ray: Pneumopeitoneum in ~50% of perforations.US: Hepatomegaly 
Additional Investigations • 24-hr luminal pH + manometry confirms diagnosis by showing correlation between low oesophageal pH and symptoms. N/A • ERCP: Further imaging and therapeutic. • ERCP: Further imaging and therapeutic. As above • Urea breath test for H. Pylori. • biopsy to test: 1. H. Pylori presence with rapid urease test; 2. Culture; 3. Histological analysis. • Stool test: 96% sensitivity; 97% specificity. Immunoassay detects presence/ absence of H. Pylori before and after TX. [Patient must discontinue PPIs 1 week prior to testing.] N/A 
Full Article GORDGallstonesCholecystitisAscending CholangitisUpper GI bleedPeptic Ulcer DiseaseHepatitis