Right upper quadrant abdominal pain

Background

• This page outlines the general approach to right upper quadrant (RUQ) pain
• RUQ contains: liver, gallbladder, hepatic flexure of colon, right kidney, duodenum, head of pancreas
• Biliary disease (cholelithiasis, cholecystitis, choledocholithiasis, cholangitis) is the most common cause of RUQ pain
• Key EM considerations: RUQ pain can also be from hepatic pathology, pneumonia (right lower lobe), or cardiac disease (right heart failure, pericarditis)
• HELLP syndrome and preeclampsia must be considered in pregnant patients with RUQ pain

Classification by Abdominal pain location

Side-by-side comparison of quadrants and regions.

Chart of commonly reported referred pain sites.

RUQ pain	Epigastric pain	LUQ pain
Flank pain	Diffuse abdominal pain	Flank pain
RLQ pain	Pelvic pain	LLQ pain

Clinical Features

History

• Onset, character, duration, radiation (right shoulder/scapula suggests biliary)
• Relationship to meals: postprandial, especially fatty foods (biliary colic)
• Fever, chills (cholecystitis, cholangitis, hepatic abscess)
• Jaundice, dark urine, pale stools (biliary obstruction)
• Nausea/vomiting
• Prior episodes (recurrent biliary colic)
• Prior cholecystectomy (consider choledocholithiasis, bile duct stricture)
• Pregnancy status
• Alcohol use, hepatotoxic medications (hepatitis)
• Travel history, immunosuppression (hepatic abscess, hepatitis)

Physical Exam

Gallbladder anatomy (overview).

Gallbladder anatomy.

• Murphy sign: inspiratory arrest during RUQ palpation — highly suggestive of cholecystitis
• Hepatomegaly, liver tenderness
• Jaundice, scleral icterus
• Charcot triad (fever + RUQ pain + jaundice) = cholangitis
• Reynolds pentad (Charcot triad + hypotension + AMS) = severe/suppurative cholangitis
• CVA tenderness (pyelonephritis)
• Decreased breath sounds at right base (pneumonia, pleural effusion)

Red Flags

• Charcot triad or Reynolds pentad (biliary sepsis)
• Hemodynamic instability
• RUQ pain in pregnancy (HELLP, preeclampsia)
• Rapidly progressive jaundice
• Peritoneal signs (gallbladder perforation)
• Hepatomegaly with ascites and encephalopathy (acute liver failure)

Differential Diagnosis

RUQ Pain

• Gallbladder disease
  • Symptomatic cholelithiasis (biliary colic)
  • Choledocholithiasis
  • Acute cholecystitis
  • Ascending cholangitis
  • Acalculous cholecystitis
• Pancreatitis
• Acute hepatitis
• Pancreatitis
• GERD
• Appendicitis (retrocecal)
• Pyogenic liver abscess
• Bowel obstruction
• Cirrhosis
• Budd-Chiari syndrome
• GU
  • Pyelonephritis
  • Kidney stone
  • Fitz-Hugh-Curtis Syndrome
• Other
  • Hepatomegaly due to CHF
  • Peptic ulcer disease with or without perforation
  • Pneumonia
  • Herpes zoster
  • Myocardial ischemia
  • Pulmonary embolism
  • Abdominal aortic aneurysm

Must Not Miss

• Cholangitis: biliary sepsis, can rapidly decompensate
• HELLP syndrome: pregnant patient with RUQ pain, elevated LFTs, thrombocytopenia
• Hepatic abscess: fever, RUQ pain, sepsis
• Right lower lobe pneumonia: referred RUQ pain
• Ruptured hepatic adenoma/hepatocellular carcinoma: hemorrhage
• Budd-Chiari syndrome: acute hepatic vein thrombosis

Evaluation

Laboratory

• CBC with differential
• BMP
• LFTs: AST, ALT, alkaline phosphatase, bilirubin (direct and total)
• Lipase (pancreatitis)
• Coagulation studies (PT/INR — marker of liver synthetic function)
• Urinalysis
• Urine pregnancy test (females of reproductive age)
• Blood cultures if febrile or concern for cholangitis
• Lactate if sepsis suspected

Imaging

• RUQ US (first-line for RUQ pain): gallstones, gallbladder wall thickening, pericholecystic fluid, CBD dilation, Murphy sign on ultrasound
• POCUS: can identify gallstones and free fluid at bedside
• CT abdomen pelvis with IV contrast: when diagnosis unclear, or to evaluate complications (abscess, perforation, mass)
• CXR: right lower lobe pneumonia, pleural effusion, free air
• MRCP or ERCP: for suspected choledocholithiasis or cholangitis (ERCP is both diagnostic and therapeutic)
• HIDA scan: if cholecystitis suspected but ultrasound equivocal

Management

• IV fluids, analgesia (NSAIDs effective for biliary colic), antiemetics
• Biliary colic: pain management, outpatient surgical referral for cholecystectomy
• Cholecystitis: IV antibiotics, surgical consultation for cholecystectomy (usually within 24-72 hours)
• Choledocholithiasis: GI consultation for ERCP
• Cholangitis: emergent ERCP for biliary drainage, IV antibiotics, ICU monitoring if hemodynamically unstable
• Hepatitis: supportive care, identify etiology
• Hepatic abscess: IV antibiotics, IR-guided drainage, ID consultation
• HELLP/Preeclampsia: OB consultation, delivery planning, magnesium sulfate

Disposition

• Admit: cholecystitis, cholangitis, hepatic abscess, pancreatitis, HELLP, acute liver failure, GI bleeding
• Observation: equivocal cholecystitis, pending HIDA scan results
• Discharge: biliary colic with resolved pain and reliable outpatient surgical follow-up; hepatitis with stable labs and close PCP follow-up
• Return precautions: fever, worsening pain, jaundice, vomiting, inability to tolerate oral intake

See Also

• Abdominal Pain
• Cholecystitis
• Cholangitis
• Cholelithiasis
• Pancreatitis