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12-19-2008, 08:22 AM
RUQ pain is often due to biliary disease or hepatitis. Inflammation from an ascending appendix, MI, or renal disease should be excluded from the differential. In the condition that is sometimes inappropriately termed biliary colic, the pain is steady rather than paroxysmal. The pain of biliary colic is generally described as a constant gnawing that increases over a few hours postprandially and then subsides totally; it is due to increased pressure buildup in the gallbladder as an outlet obstruction causes it to contract. Acute cholecystitis occurs with prolonged blockage in the duct system; patients will present with steady, severe pain that may radiate to the subscapular region; nausea, bilious vomiting, and anorexia are common. If fever is present, the diagnosis is more likely to be cholecystitis than simple biliary colic. On physical examination, the most accurate diagnostic findings for acute cholecystitis are a positive Murphy’s sign,.Other disease processes of the biliary system includ e acute cholangitis occurring when a stone lodges in the biliary or hepatic duct system, causing dilation and infection. The patient with acute cholangitis may present with jaundice, fever, and abdominal pain; laboratory studies may show a high WBC count, elevated bilirubin and pancreatic enzymes, and possible elevation in LFT results.The pain of hepatitis is rarely acute at onset. The entire liver is tender to palpation, and pressure placed laterally over the intercostals will elicit pain; this characteristic helps to distinguish hepatitis from biliary tenderness, which is felt mainly over the right hypochondrium. Elevated bilirubin levels will cause the classic signs of jaundice as well as scleral icterus. Ascites may also be present due to underlying portal hypertension caused by chronic liver disease, and laboratory studies will show elevated LFT results early in the disease process. The pain from MI can be high in the epigastrium and thus may be difficult to differentiate from biliary pain. Biliary colic and acute cholecystitis are two of the most common noncardiac reasons patients are admitted to cardiac care units.There are times when patients cannot pinpoint the location of their abdominal pain. As discussed previously, mesenteric ischemia and infarct are possible diagnoses. Other causes of diffuse abdominal pain include peritonitis and gastroenteritis.Peritonitis may cause a patient to try to lie strictly immobile, often with knees bent. Pain from peritonitis becomes more diffuse as the infection spreads away from the originating organ. Patients will generally be febrile, tachycardic, and hypotensive, and abdominal examination will reveal a diffusely tender abdomen, even with gentle palpation.Gastroenteritis can cause abdominal pain, especially cramping, along with diarrhea, nausea, and vomiting. Knowledge of recent exposure and illnesses within close contacts or the community can help lead to this diagnosis. Most cases are self-limiting, but special concern and treatment may be necessary for immunocompromised and elderly patientsLeft upper quadrant (LUQ) pain may be attributable to pathology involving the spleen and the pancreas. Acute pancreatitis manifests as rapid onset, steady pain boring straight through to the back Gallstones are the most common cause of pancreatitis in the United States, causing pain and inflammationRight lower quadrant (RLQ) pain is classically caused by appendicitis. Patients usually report having periumbilical pain, which then radiates to the RLQLeft lower quadrant (LLQ) pain indicates diverticulitis in 70% of patients with this condition in the Western world.19 Patients with this pancolonic process present very similarly to those with appendicitis—with a few noteworthy exceptions, such as more pronounced changes in bowel habits. Fever and leukocytosis ar e more prominent in diverticulitis, while one often sees anorexia, vomiting, and nausea in appendicitis. Initial pain with diverticulitis is usually hypogastric rather than epigastric and radiates to the left iliac crest or suprapubic area. Patients suffering from an acute attack of diverticulitis probably have experienced this type of pain before; if elicited in the history, this information can thus give a good diagnostic clue.
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