View source for 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
{{Abdominal pain location}}

==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===
[[File:Gallbladder (organ).png|thumb|Gallbladder anatomy (overview).]]
[[File:GallbladderAnatomy-en.svg|thumb|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==
{{DDX RUQ}}

===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]]

==External Links==

==References==
<references/>

[[Category:GI]]
[[Category:Symptoms]]