Right Upper Quadrant Pain Flashcards
What are the main differentials of a 38 woman presenting with right upper quadrant pain?
Biliary Colic
Cholecystitis
Duodenal ulcer
Pancreatitis
Basal pneumonia
Ascending cholangitis
Gastric ulcer SBO Appendicitis (atypical) Hepatitis Pyelonephritis Ovarian pathology
What questions should you ask in a patient with right upper quadrant pain?
SOCRATES
Other symptoms (fever, weight loss etc.)
When did they last open their bowels/pass any flatus?
Any changes to stool?
If females, any change of pregnancy?
What is Boas’ sign?
Sharp stabbing sensation in the right scapula associated with cholecystitis
What is Cullen’s or Grey Turner’s sign?
Bruising and discolouration around the umbilicus and flank
What is Murphy’s sign?
How is it elicited?
Tenderness of the gallbladder on inspiration
Palpate the abdomen just below the tip of the right ninth costal cartilage
What are the signs of peritonitis?
The patient will lie very still, have a rigid and exquisitely tender abdomen, and exhibit guarding upon light palpation
What are the signs of SBO?
Tinkling or absent bowl sounds
If the bowel becomes strangulated then peritonitis would predominate
How can a cholecystitis be managed?
Non-operatively
- Nil by mouth
- IV fluids
- Analgesia
- Antibiotics
Operative
- Laparoscopic cholecystectomy
Both liver disease or a blocked common bile duct (obstructive jaundice) can cause patients to have prolonged blood clotting times, but administering parenteral (not oral) vitamin K will only correct the problem in one of the cases: which one and why?
An increased PT due to liver disease will not be corrected by the parenteral administration of vitamin K as
the problem is the liver, not the lack of vitamin K. Conversely, parenteral vitamin K will correct a prolonged PT that is due to obstructive jaundice (because clotting factor synthesis is only being impaired by a lack of raw
material – vitamin K, rather than impaired synthetic ability).
Which patients are prone to bile pigment stones?
Bile pigments are haemoglobin breakdown products and thus patients with haemolytic anaemias (Eg hereditary spherocytosis, sickle cell disease, or G6PD deficiency) are predisposed to these sort of stones
Which patients are prone to cholesterol stones?
Fair, fat, fertile female of forty
Use of OCP further increases the risk of cholesterol stones
Patients with Crohn’s disease may suffer higher rates of cholesterol stones because the terminal ileum pathology impairs reabsorption and enterohepatic circulation of bile salts, thus making bile-based stones less likely
What is a gallstone ileus?
When a gallstone travels through a cholecystoduodenal fistula and becomes stuck, obstructing the small bowel
Why does the consumption of fatty food exacerbate the pain of biliary colic and chronic cholecystitis?
Cholecystokinin is released from the duodenum in response to fatty foods and stimulates the contraction of the gallbladder and relaxation of the sphincter of Oddi
What is Calot’s triangle?
An anatomical zone used to define the usual path of the cystic artery, the cystic duct, and the common hepatic duct, and the common duct
Superior border is the liver
Inferior border is the cystic duct
Medial border is the common hepatic duct
Where would a gallstone need to be in order to cause obstructive jaundice?
Common bile duct or the ampulla of Vater
Also a stone in Hartmann’s pouch may also press extrinsically on the bile duct (Mirizzi’s syndrome)
