RUQ Pain

RUQ Pain

1. cholelithiasis

   • factors that predispose: age, FH, Female, fat, hx recent pregnancy, hx previous gallstones
   • symptoms: fever, pain, guarding, Murphy sign (inspiratory arrest during deep palpation RUQ). pain may also be epigastric or radiate to back
   • diag: ultrasound. on labs, mild leukocytosis, mild jaundice w/ elelvated bilirubin, elevated alk phos, maybe tranaminases
     • standard tx: cholecystectomy.
       • antibiotics: single dose of 1st gen cephalosporin unless risk of sepsis (age over 70, acute cholecystitis, hx of obstructive jaundice/common ducts stones). also puts who have undergone ERCP.
       • procedure steps: remove gallbladder at junction of cystic and common duct (must remove fundus from bed of liver). also ligate cystic artery.
         • possible complications: injury to common duct, leading to chronic biliary strictures, infection or cirrhosis. may also injure hepatic artery.
           • if get post-op fever and pain, think infection or biliary leak. do ultrasound and HIDA scan (hepatobiliary nuclide scan). scan detect leaks and acute cholecystitis (fail to visualize gallbladder). if don't find anything, follow patient. if find leak or obstruction, do ERCP to define biliary anatomy. if see leak, drain and put in temporary stent. if bile duct obstructed, drain and create new anastomosis with GI tract (choledochojejunostomy).
         • post-op management: send home once recovery from anesthesia. seen outpatient in 1 wk
     • if have jaundice or elevated liver enzymes, suspect obstruction of common bile duct. ultrasound to confirm. must clear if stones present (unless very small- observe b/c may pass). do ERCP in addition to cholecystectomy or cholecystectomy with intro cholangiogram and common duct exploration
     • if pregnant, manage non operatively with hydration and pain management. if recurrent episodes, surgery ro ERCP justifiable. cholecystecomy safer than ERCP (2nd semester best). If can wait, to after delivery.
     • if elevated amylase, may also have mild pancreatitis (either from inflammation of adjacent gallbladder or from common duct stone). require cholangiogram in addition to cholecystectomy. if patient becomes ill from pancreatitis (hemodynamic instability, hypocalcemia, oliguria, pulmonary complications) must delay surgery. if it is a common duct block, ERCP.

2. biliary colic

3. acute cholecystitis

   • tx: antibiotics after obtaining blood cultures. usually gram-neg/anaerobes prep and for 24 hour post-op (cholecystectomy recommended within 48-72 hrs). organism usually E. Coli, Enterobacter, LKlebsiella, Enterococcus. 2nd gen cephalosporin usually sufficient.

4. if young female also include:

   • gastroenteritis, PUD, acute hepatitis, renal colic, pleural-based pneumonia, pyelonephritis
     • suspect PUD or gastritis w/ hx indigation, NSAIDS, antacids, tarry stool, ethanol abuse

5. gallbladder empyema

   • diagn: ultrasound with gallstones and gallbladder distended with fluids
   • tx: IV antibiotics, emergent exploration with cholecystectomy

6. acute cholangitis (obstruction of biliary tree with superimposed infection). charcot's triad of fever, jaundice, pain. if severe, can also have shock and altered mental status (reynolds pentad)

   • suppurative cholangitis (find def). tx stabilize with IV fluids/antibiotics. ERCP with sphincterotomy, decompression of biliary tree (ex. if bacteria gas forming)l
   • pancreatic cancer can also create these symptoms, but rare

7. acute biliary sepsis

   • symptoms: fever, hypotension, leukocytosis. if elderly patient, may instead have hypothermia/leukopenia (don't be confused by low WBC count)
   • tx: antibiotics, resuscitation. surgery

8. emphysematous gallbladder. gas-forming organism invaded tissues

9. hepatic lesions

   • solid lesion on ultrasound
     • benign
       • hemangioma: typically asymptomatic. dx: labeled RBC scan. usually don't need removal. don't biopsy b/c risk bleeding.
       • hepatic adenom. hx of OCP use (can regress w/ discontinue). should resect persistent or large lesions. risk of rupture esp during pregnancy so should be resected prior to pregnancy
       • focal nodular hyperplasia (solid). may see central stellate scar on CT scan, but need liver biopsy to confirm. No tx needed.
     • malignant. do CT abdomen/chest to find metastasis. if none, surgical assessment.
       • metastatic carcinoma
       • primary hepatocellular carcinoma. hx hep B/C, alpha-FP. prognonsis good if solitary, small (resectable within 1cm margin, w/o vascular invasion, low-grade). if multiple lesions or involved critical vasculature, don't resect.
       • cholangiocarcinoma
   • cyst (see fluid on ultrasound)
     • simple cyst usually asymptomatic. usually no further management needed. if symptoms persist, aspiration + sclerosant or excision. if multiple cysts, check for PCKD b/c then has polycystic liver disease. tx same as simple cysts
     • multilocular cyst w/ calcification in the wall
       • echinococcal cyst from GI parasite. do serologic test. tx: inject cyst in OR w/ hypertonic saline and excise cyst. don't spill b/c risk of infecting peritoneal cavity.
     • absess (occur from partial or complete obstruction of biliary system with spread of bacteria up tree) see fever, leukocystosis,. tx IV antibiotics and CT-guided drainage.
       • pyogenic (bacterial)
         • if single large, drain and give antibiotics via catheter for 2-3wks. if multiple small, broad spectrum IV antibiotics 4-6 wk. obtain culture to determine antibiotic
       • ameobic. ex. E. hystolytica give metronidazole alone.