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Pain in the right upper quadrant (RUQ) can be caused by a wide variety of conditions. The age, sex and general condition of the patient will influence the likely diagnosis. History and examination will also focus the differential diagnosis. Features such as acute or chronic onset, weight loss, pyrexia, general malaise, and urinary or bowel symptoms may all help point to a diagnosis. It is important to decide if there is an acute abdomen. There are related separate articles Left Upper Quadrant Pain, Abdominal Pain, Abdominal Pain in Pregnancy and Abdominal Pain in Children.
Enquire first about the pain:
- Ask the patient to point to where it is. Note whether the patient uses a single finger or indicates the area is more diffuse.
- Ask the patient to confirm when the pain started.
- Determine whether onset was sudden or gradual.
- Establish whether pain is continuous or intermittent.
- Ask the patient to describe the nature of the pain - stabbing, burning, gripping, etc. Note the body language and use of hands.
- Ask the patient whether there are aggravating or relieving factors.
- Establish whether there is any radiation.
Note past medical history. Make a systematic enquiry. The patient may volunteer information such as pyrexia, cough or dysuria. Discuss:
- Any change in weight
- Smoking and drinking
Family history may be revealing.
- Note the general condition of the patient - ie whether they are fairly well, shocked, pyrexial or dyspnoeic. Note whether there is jaundice.
- Note temperature, pulse rate and quality, and blood pressure.
- The patient should be adequately disrobed and both the patient and the examiner should be in a comfortable position. A systematic examination of all the abdomen is required. Abdominal examination is described elsewhere. See separate article Abdominal Examination.
- A full examination is required of other bodily systems - eg, examination of the respiratory system, especially if the diagnosis is elusive.
The crude differential diagnosis is vast but after adequate history and examination it should be very much smaller. The following order is not intended to indicate likelihood:
Liver and gallbladder disease
- Liver disease is usually only painful if it stretches the capsule of the liver, as in congestive heart failure. The liver can be damaged by blunt trauma. Hepatosplenomegaly can occur with malignancy such as lymphoma or chronic myeloid leukaemia or with autoimmune disease including primary biliary cirrhosis.
- The Budd-Chiari syndrome can present with RUQ pain.
- Gallstones are common and become more common as years advance. Most are asymptomatic but they can cause pain at any time.
- Other gallbladder disease includes carcinoma of the gallbladder, which is always associated with stones too.
- Ascending cholangitis has a classic triad of pain, fever and jaundice.
- Lesions of the hepatic flexure include carcinoma, diverticular disease, ischaemic colitis, constipation and Crohn's disease.
- Atypical acute appendicitis must be considered.
- Recurrent symptoms can be caused by irritable bowel syndrome.
- Meckel's diverticulum can present in a variety of ways, usually in children. The diagnosis is usually made at laparotomy. There is often blood loss per rectum.
- Pain from a dissecting abdominal aortic aneurysm is usually most marked in the back and may originate in the chest and spread down the legs. Other arteries can have aneurysms and bleed.
- Cardiac pain may occasionally present as upper abdominal pain.
- Congestive cardiac failure may stretch the liver capsule.
- Renal cancer.
- Other disease of the kidney or ureter, including obstruction of the urinary tract.
Pain may arise from the right lower lobe of the lungs.
- Lobar pneumonia.
- Infarction from pulmonary embolism. If this is suspected, check for evidence of deep vein thrombosis.
Endocrine or exocrine disease
- Diabetic ketoacidosis.
- Addisonian crisis.
- Adrenal tuberculosis.
- Metastatic carcinoma.
- Pain from the pancreas tends to be central and higher in the back, often between the scapulae, although it can be atypical and misleading. Amylase is raised in intestinal obstruction but in acute pancreatitis it is very high.
- Carcinoma of pancreas tends to produce an aching pain between the scapulae, eased on leaning forward.
- Herpes zoster can present as pain before the typical vesicles appear on the skin. It is the skin that is tender rather than deeper structures.
- Subphrenic abscess or even gas after laparotomy or, more often, laparoscopy. Again pain may be referred to the shoulder.
- A rare condition is Fitz-Hugh and Curtis syndrome. There is inflammation of the liver capsule associated with genital tract infection. It is said to occur in up to one fourth of patients with pelvic inflammatory disease. Classically it presents as sharp, pleuritic RUQ pain but signs of salpingitis can be absent.
The last trimester of pregnancy gives added problems. Minor elevations of liver enzymes may precede life-threatening disease, such as acute fatty liver of pregnancy (AFLP) or a syndrome of late pregnancy with Haemolysis, Elevated Liver enzyme levels, Low Platelet count (HELLP).
Pre-eclampsia, HELLP syndrome, and AFLP form a spectrum of disease that ranges from mild symptoms to severe life-threatening multiorgan dysfunction. They have been shown to be the primary causes of severe hepatic dysfunction during pregnancy.
- Pain may be referred from nerves in the spinal column or peripheral nerves that supply the area. Spinal tuberculosis is a rare cause of abdominal pain.
- Recurrent abdominal pain is not uncommon in endurance athletes and its diagnosis can be difficult.
- Children are very nonspecific about 'tummy pain' and almost anything can present as such. Check ears, throat and urine. Mesenteric adenitis commonly presents with mild pyrexia and probably other lymphadenopathy.
- Lesions associated with left upper quadrant pain may occasionally present on the other side. Situs inversus occurs in 1 person in 10,000.
This list is by no means exhaustive. There are many other rarer causes of abdominal pain, including familial Mediterranean fever, tabes dorsalis and worm infestation. There is also the possibility of Münchhausen's syndrome.
The choice of investigations will depend upon the findings above.
- FBC, ESR and CRP may give an indication of infection or an inflammatory process. Bleeding may cause anaemia. This may indicate malignancy.
- Abnormal LFTs will occur if the liver is involved and in primary biliary cirrhosis there will be positive anti-mitochondrial autoantibodies. It usually presents in a middle-aged woman with jaundice and pruritus.
- Urinalysis may suggest urinary tract infection, including pyelonephritis or a lesion that causes microscopic bleeding, such as stones or malignancy.
- CXR and lateral view may show a lesion of the right lower lobe. Collapse from infection and infarction look similar. Plain abdominal X-rays, erect and supine, may show abnormal bowel patterns, fluid levels or gas or fluid under the diaphragm. 70% of renal stones and 30% of gallstones are radio-opaque.
- Colonoscopy or double-contrast barium enema may be required for colonic lesions.
- Ultrasound is useful to investigate the renal tract for stones or dilatation. It is the best way to detect gallstones. It can also be used to check the liver for enlargement and establish if it has a homogeneous pattern or areas of different echo density.
- To investigate the spinal column, CT scan is good at revealing lesions of bone; however, MRI scan is better at showing lesions of the nervous system.
- Abdominal CT or MRI scan may be useful to define a lesion. In overweight people, in whom ultrasound can be difficult, MRI scanning gives similar results. Radio-isotope imaging can show the liver and spleen.
- In pregnancy, MRI may be the preferred option. However, CT scanning is increasingly being used in specific cases - eg, it is the most reliable method of diagnosing patients with suspected obstruction of the urinary tract due to calculus. Studies suggest that the risk to the fetus from the ionising radiation involved in CT scanning is minimal. If a risk-benefit analysis confirms that CT would be in the patient's best interests, it should not be withheld.
Further reading & references
- Acute abdomen; Paediatric Oncall Child Health Care
- Cartwright SL, Knudson MP; Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008 Apr 1;77(7):971-8.
- Zimmerman MA, Cameron AM, Ghobrial RM; Budd-Chiari syndrome. Clin Liver Dis. 2006 May;10(2):259-73, viii.
- Peter NG, Clark LR, Jaeger JR; Fitz-Hugh-Curtis syndrome: a diagnosis to consider in women with right upper quadrant pain. Cleve Clin J Med. 2004 Mar;71(3):233-9.
- Steingrub JS; Pregnancy-associated severe liver dysfunction. Crit Care Clin. 2004 Oct;20(4):763-76, xi.
- Elgendy AY, Mahmoud A, Elgendy IY; Abdominal pain and swelling as an initial presentation of spinal tuberculosis. BMJ Case Rep. 2014 Feb 19;2014. pii: bcr2013202550. doi: 10.1136/bcr-2013-202550.
- Dimeo FC, Peters J, Guderian H; Abdominal pain in long distance runners: case report and analysis of the literature. Br J Sports Med. 2004 Oct;38(5):E24.
- Kim JS; Acute Abdominal Pain in Children. Pediatr Gastroenterol Hepatol Nutr. 2013 Dec;16(4):219-224. Epub 2013 Dec 31.
- Miller AH, Pepe PE, Brockman CR, et al; ED ultrasound in hepatobiliary disease. J Emerg Med. 2006 Jan;30(1):69-74.
- Oh KY, Gilfeather M, Kennedy A, et al; Limited abdominal MRI in the evaluation of acute right upper quadrant pain. Abdom Imaging. 2003 Sep-Oct;28(5):643-51.
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Dr Gurvinder Rull
Dr Gurvinder Rull
Dr Adrian Bonsall