Family Medicine 15: 42-year-old male with right upper
quadrant pain
User: Val Molloy
Email: vmolloy@luc.edu
Date: July 14, 2022 11:03 PM
Learning Objectives
The student should be able to:
Conduct a focused history and physical exam for a patient presenting with abdominal pain.
Discuss who should be screened and how to screen for alcohol abuse/dependence depending on age and risk.
Demonstrate performance of a focused history and physical examination for a patient with abdominal pain and differentiate
between common and "don't miss" etiologies.
Propose a cost-effective diagnostic work-up for a patient presenting with abdominal pain.
Describe the initial management of common diseases that present with right upper quadrant abdominal pain.
Describe an evidence-based management plan that includes surveillance and treatment of alcohol use disorder.
Find and apply diagnostic criteria for alcohol use, dependence, and abuse.
Assess improvement or progression of substance use, dependence, and abuse.
Knowledge
AUDIT Screening for Alcohol Abuse/Dependence
The AUDIT-C Test is a three-item, validated screening instrument utilized to help identify hazardous drinking behavior or
individuals with active alcohol use disorders (including alcohol use disorder or dependence).
AUDIT-C
Question 1: How often did you have a drink containing alcohol in the past year?
Never (0 points)
Monthly or less (1 point)
Two to four times a month (2 points)
Two to three times per week (3 points)
Four or more times a week (4 points)
Question 2: How many drinks did you have on a typical day when you were drinking in the past year?
1 or 2 (0 points)
3 or 4 (1 point)
5 or 6 (2 points)
7 to 9 (3 points)
10 or more (4 points)
Question 3: How often did you have six or more drinks on one occasion in the past year?
Never (0 points)
Less than monthly (1 point)
Monthly (2 points)
Weekly (3 points)
Daily or almost daily (4 points)
The AUDIT-C is scored on a scale of 0-12. Per the NHS a score of 5 or more triggers more questions. If the total is over 7 that
suggests that the individual is engaging in risky drinking and would warrant further conversation regarding alcohol use and/or
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additional screening using tools such as the AUDIT-10 to assess severity.
Furthermore, the American Society of Addiction Medicine has developed standards for a positive screen based on the number of
drinks ingested per week. Consumption of more than 14 drinks per week or more than four drinks per occasion for males, and
more than seven drinks per week or more than three drinks per occasion for females is considered a positive screen.
Mr. Keenan likely scores more than 7 so this is a concern you note to address at some point either now or on a future visit.
Classifying Alcohol Use
Moderate drinking refers to alcohol consumption up to one drink per day for females and up to two drinks per day for males.
Binge drinking is defined by the Substance Abuse and Mental Health Service Administration (SAMHSA) as the consumption of
five or more alcoholic beverages on one occasion on one or more days in a 30-day period.
Heavy drinking is defined by SAMHSA as consuming five or more alcoholic drinks on a single occasion, five or more days in a 30day period.
Alcohol use disorder: According to the DSM 5, AUD is diagnosed when patients endorse two or more of the following:
Persistent desire to or unsuccessful attempts to cut down or stop drinking.
Spending a lot of time obtaining alcohol, drinking alcohol, or recovering from the after-effects of drinking.
Experience craving—a strong need, or urge, to drink.
Drinking—or being sick from drinking—has often interfered with taking care of their home or family; has caused job troubles
or school problems.
Continue to drink even though it causes trouble with family or friends.
Giving up or cutting back on activities that were important or interesting to the patient or gave them pleasure, in order to
drink.
More than once have been in situations during or after drinking that increased the patient's chances of getting hurt (such as
driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex).
Continue to drink even though it makes the patient feel depressed or anxious or adds to another health problem, or after
having had a memory blackout.
Have to drink much more than they used to in order to get the effect they wanted, or find that their usual number of drinks
have much less effect than before.
Find that when the effects of alcohol are wearing off, the patient has withdrawal symptoms, such as trouble sleeping;
shakiness; irritability; anxiety; depression; restlessness; nausea; or sweating, or senses things that are not there.
Alcohol use disorder severity is graded according to the following:
Mild: two to three symptoms.
Moderate: four to five symptoms.
Severe: six or more symptoms.
Likelihood of Maintaining Sobriety
The statistics are limited, but we do know that higher rates of relapse occur in individuals who are men, younger age, have fewer
social supports, who drank more prior to treatment, and, when applicable, have poor compliance with drug therapy.
Clinical Skills
Abdominal Exam: Appendicitis
The physical exam findings of acute appendicitis vary from person to person, and no one finding can either rule in or rule out the
diagnosis in a person with a presentation suggestive of appendicitis. Several common findings have been described and are
routinely documented.
Psoas sign: Pain in the right lower quadrant (RLQ) that occurs upon passive extension of the patient's thigh as they lie on their
side with knees extended, or upon active or resisted flexion of the hip; may be positive with acute appendicitis.
Psoas sign video
Obturator Sign: With patient supine and right hip flexed to 90 degrees, examiner holds patient's right ankle in their right hand
as they use their left hand to internally rotate patient's hip by moving the knee medially. Pain in the RLQ may indicate acute
appendicitis.
Obturator sign video
Indirect Tenderness (also called Rovsing’s Sign): This is positive when palpation in the left lower quadrant elicits pain in the
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right lower quadrant. When positive, it indicates RLQ peritoneal irritation.
McBurney’s Sign: This is positive when there is tenderness at McBurney’s point, which is approximately one-third of the way
from the anterior superior iliac spine (ASIS) and the umbilicus.
Management
Management of Biliary Colic
Surgical consultation for cholecystectomy is recommended as the best course of action to ensure patients with biliary colic
are fully informed of their options for definitive surgical treatment, including the risks of surgery, long-term outcomes, and the
risks of progression of disease or complications if a non-surgical option is chosen.
Expectant management or "watchful waiting" is likely not the best option, as natural history studies document a 70% risk of
progression over two years to complications such as acute cholecystitis, cholangitis, pancreatitis, choledocholithiasis, gallstone
ileus, and Mirizzi syndrome (gallstone compression of the hepatic duct). Patients who choose “watchful waiting” should generally
only do so after surgical consultation has been accomplished.
A three-month trial of ursodiol (Actigall) —an agent that is sometimes effective in dissolving gallstones and preventing future
gallstones—carries a similar risk to watchful waiting for most patients with symptomatic gallstones. It may be an option for some
patients who are unable or unwilling to undergo cholecystectomy, or for those who have atypical symptoms that are not clearly
attributed to gallstones, and/or who have stones that are small in size (less than 5mm). These patients should be monitored
closely for recurrent symptoms, and potentially receive follow-up RUQ ultrasound to assess for dissolution.
Further imaging at this time is probably not warranted. If the patient has typical symptoms of biliary colic but no visible stones
on the gallbladder ultrasound, a HIDA scan might be obtained to look for gallbladder dysfunction and reproducible pain.
If there was jaundice and/or gallstone pancreatitis suggestive of a common duct stone (choledocholelithiasis), an ERCP might be
warranted.
Another role for ERCP is in the postoperative patient who did not have an intraoperative cholangiogram (assessing the common
duct at the time of surgery) and who presents with a repeat episode of biliary colic and/or jaundice and/or pancreatitis. MRCP is a
similar diagnostic modality that uses magnetic resonance. However, unlike ERCP—where treatment can take place at the time of
diagnosis—MRCP is a diagnostic modality only.
Intervention and Treatment of Alcohol Use Disorder
Brief intervention by the family physician consists of a 10-to-15 minute session sharing advice and goal-setting.
Usually, this is followed by a return visit or phone call. This may be a practical first option for a patient in a rural area who
may not be able to seek regular or frequent care.
Treatment with medication: The Agency for Healthcare Research and Quality found moderate evidence to support the
use of naltrexone and acamprosate for the treatment of alcohol use disorder.
Referral for MET which consists of four sessions over 12 weeks and utilizing motivational interviewing techniques. This
intervention requires more of a commitment from the patient to attend sessions. This modality may not be available in rural
areas.
Referral for CBT, a structured form of psychotherapy that works to improve the patient's awareness of behavior and to
develop new, more adaptive behaviors. Also requires patient commitment and may not be readily accessible in a rural area.
Voluntary participation in a mutual support group. AA https://www.aa.org/what-is-aa is one option that is available in
almost all regions and utilizes group support and a 12-step process that emphasizes total alcohol abstinence. AA’s 12 steps
are spiritual principles that may be beneficial for some and challenging for others. Other more secular mutual support
groups include Women for Sobriety (WFS), SMART Recovery (Self-Management and Recovery Training), and Secular
Organizations for Sobriety/Save Our Selves (SOS).
Studies
Studies to Evaluate Right Upper Quadrant Abdominal Pain
CBC (complete blood count) is indicated to assess for leukocytosis that would suggest infection or acute inflammation (such as
in acute cholecystitis) and to assess for anemia that might suggest internal bleeding.
Electrolytes are indicated to assess for electrolyte alterations that may occur due to persistent nausea and vomiting, diarrhea, or
reduced oral intake.
Liver chemistries are indicated to assess for acute or chronic hepatic cell injury (elevated ALT and AST) and to assess for biliary
tract involvement (elevated alkaline phosphatase and total bilirubin).
UA (urinalysis) is an inexpensive point-of-care test. It would be useful in a patient with flank pain; it assesses for urinary red
blood cells that might occur due to kidney or ureteral stones. It also assesses for urinary tract infection, including of
pyelonephritis. A urine urobilinogen elevation could also point to jaundice in hepatitis.
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Lipase is the preferred test to assess for acute pancreatitis and is more sensitive and specific than amylase.
Imaging Right Upper Quadrant Abdominal Pain
In general, real-time abdominal ultrasonography is the preferred imaging study to evaluate the right upper quadrant because it
is inexpensive, noninvasive, and widely available. It provides a good evaluation of the liver and other viscera such as the
gallbladder, and it is accurate in the detection of gallstones and dilation of the biliary tree.
Abdominal plain films (upright and supine) are often readily available and relatively inexpensive compared to the other imaging
studies listed. However, plain films are not the most sensitive modality for evaluation of the right upper quadrant. Plain films are
useful for detecting free air in the peritoneal cavity and signs of bowel obstruction (such as dilated loops of bowel and air-fluid
levels), making it the initial imaging modality of choice for suspected bowel perforation or obstruction.
Abdominal CT scan with contrast is more appropriate for the initial workup of lower quadrant abdominal pain such as that due to
appendicitis or diverticulitis. It is relatively less sensitive for evaluating the anatomy and pathophysiology of the right upper
quadrant. Additionally, it is more expensive and exposes the patient to potentially unnecessary radiation.
Abdominal MRI, although very sensitive, is expensive, resource-intensive, and not generally as readily available as a rapid imaging
modality, particularly in acute potentially life-threatening conditions involving the abdomen. It would not be a first-choice study
before ultrasound in this scenario.
Clinical Reasoning
Differential Diagnosis of Right Upper Quadrant Abdominal Pain
Biliary colic typically causes episodic right upper quadrant (RUQ) pain, epigastric pain, or chest pain that lasts four to six hours or
less, and often radiates to the back (classically under the right shoulder blade). It is often accompanied by nausea or vomiting and
often follows a heavy, fatty meal. These symptoms are a result of a stimulated gallbladder (e.g., from a fatty meal) contracting
when a gallstone obstructs the outlet of the cystic duct. The hallmark of biliary colic is that the stone is mobile and eventually
moves away from the outlet allowing resumption of normal gallbladder function and resolution of symptoms.
RUQ pain from cholecystitis also causes right upper quadrant pain with associated nausea and vomiting and also classically
occurs following a large, fatty meal. The pathophysiology of cholecystitis is similar to biliary colic but is caused by a stone that is
lodged in the cystic duct outlet. In contrast to biliary colic, the symptoms of cholecystitis typically persist, are more severe, and
are often associated with fever. An elevated white blood cell count is often present from inflammation of the distended gallbladder
wall. It should be noted that these inflammatory changes found with cholecystitis can be acute or chronic. Additionally, the
condition of acalculous cholecystitis, in which gallstones are not implicated in the pathophysiology, can occur, particularly in the
elderly and the very ill ICU patient.
A positive Murphy's sign is the classic physical finding associated with acute cholecystitis. A negative Murphy's sign does not rule
out cholecystitis, however, as a Murphy's sign has a high specificity but low sensitivity.
Duodenal ulcer typically causes epigastric pain (possibly right or left upper quadrant pain) that is relieved rather than worsened
by food and may be relieved by antacids. While indigestion and/or nausea are common, vomiting and radiation to the back can
occur but are uncommon. However, there can be significant variation in symptoms.
The clinical manifestations of hepatitis vary somewhat depending on etiology, but most types do not have acute onset, unlike the
diseases of the gallbladder tract. While RUQ pain, nausea, and vomiting are frequently encountered, there is often associated
malaise, anorexia, itching, and icterus/jaundice. Hepatomegaly is often present, and transaminases are typically markedly
elevated (particularly in acute causes of hepatitis). The pain of hepatitis is not typically influenced by eating, contrasting it with
biliary colic, ulcer disease, and pancreatitis.
In the case of acute alcoholic hepatitis a patient would have elevated AST and, ALT, however, the elevations are generally
moderate and distinguished by an AST:ALT ratio of ≥ 2, which is rare in other liver diseases. Total serum bilirubin is also elevated.
Nausea, vomiting, and severe epigastric pain are hallmarks of acute pancreatitis. Typically there is also abdominal tenderness and
guarding on exam and symptoms are unlikely to resolve without prolonged bowel rest. Jaundice may be seen if there is obstruction
of the common bile duct. Distinguishing acute pancreatitis from biliary colic (and any other upper abdominal disease) can be
challenging, particularly because the two most common etiologies of acute pancreatitis are alcoholic pancreatitis and gallstone
pancreatitis. Gallstone pancreatitis may occur following an episode of biliary colic. With the onset of acute pancreatic inflammation
as the pancreatic duct is obstructed, the pain worsens rapidly and radiates to the back. Some classic, though rare, physical exam
signs seen in acute pancreatitis include:
1. Grey Turner sign: ecchymosis in the flank
2. Cullen sign: ecchymosis in the periumbilical region
Finally, the presentation of acute pancreatitis may include shock and/or coma.
The description above details some of the most common sources of right upper quadrant pain. It is important to have a broad
differential and recall less common causes. In the right setting these could include:
Acute myocardial infarction
Right lower lobe pneumonia or pleurisy
Herpes Zoster
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Pyelonephritis
Hepatic mass or abscess
Cholangitis
Mesenteric ischemia
Abdominal wall pain
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