Dolor en el cuadrante superior derecho

Descripción

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 abdomen agudo. There are related separate articles: Left Upper Quadrant Pain, Abdominal Pain, Abdominal Pain in Pregnancy y Abdominal Pain in Children.

Síntomas

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. [Site]

• Ask the patient what they were doing when pain started. Note whether the onset was sudden or gradual. [Dnset]

• Ask the patient to describe the nature of the pain - stabbing, burning, gripping, continuous or intermittent, etc. [Character]

• Establish whether there is any radiation. [Vadiation]

• Ask whether there are any [Associated] symptoms.

• Ask how long they have had the pain. [Time]

• Ask the patient whether there are [Exacerbating] or relieving factors.

• Establish how [Severe] the pain is - rate 'out of 10'.

Estos puntos se pueden recordar con la mnemotecnia 'SOCRATES'.

• Note past medical history. Make a systematic enquiry. The patient may volunteer information such as pyrexia, cough or dysuria. Discuss:

• • Appetite.

  • Any change in weight.

  • Bowels.

  • Urine.

  • Smoking and drinking.

  • Medication - prescribed and over the counter.

  • Family and social history may be helpful.

Signos

• 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 the separate Examen Abdominal article.

• A full examination is required of other bodily systems - eg, examination of the respiratory system, especially if the diagnosis is elusive.

El diagnóstico diferencial preliminar es amplio, pero después de una historia clínica y un examen adecuados, debería ser mucho más reducido. El orden siguiente no pretende indicar la probabilidad:

Liver and gallbladder disease

• Liver disease is usually only painful if it stretches the capsule of the liver, as in insuficiencia cardíaca congestiva. The liver can be damaged by blunt trauma. Hepatosplenomegaly can occur with malignancy such as linfoma o leucemia mieloide crónica or with autoimmune disease including cirrosis biliar primaria.

• El Budd-Chiari syndrome can present with RUQ pain.

• Cálculos biliares 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 colangitis has a classic triad of pain, fever and jaundice.

Bowel lesions

• Lesions of the hepatic flexure include carcinoma (primary or secondary), enfermedad diverticular, ischaemic colitis, constipation and enfermedad de Crohn.

• Atypical apendicitis aguda must be considered¹.

• Recurrent symptoms can be caused by síndrome del intestino irritable.

• Considere cáncer de ovario in an older woman.

• 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.

• Consider volvulus².

Enfermedad cardiovascular

• 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.

Trastornos renales

• Pielonefritis.

• Nephrolithiasis.

• Renal cancer.

• Other disease of the kidney or ureter, including hydronephrosis and obstruction of the urinary tract.

Enfermedad respiratoria

Pain may arise from the right lower lobe of the lungs.

• Lobar neumonía.

• Infarction from embolia pulmonar. If this is suspected, check for evidence of trombosis venosa profunda.

Endocrine or exocrine disease

• Cetoacidosis diabética.

• 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 pancreatitis aguda it is very high.

• Carcinoma of pancreas tends to produce an aching pain between the scapulae, eased on leaning forward.

Infecciones

• Herpes zóster 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 can occur in 4-27% of patients with enfermedad inflamatoria pélvica³. Classically it presents as sharp, pleuritic RUQ pain but signs of salpingitis can be absent.

Embarazo

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, Síndrome HELLP, 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.

Otras consideraciones

• 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 pain⁴.

• 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 lymphadenopathy⁵.

• 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 although are unable to determine acute from chronic causes⁶. 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 density⁷.

• 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.