Differential Diagnosis of Right Upper Quadrant Syndrome

General Information:

Healthcare providers often encounter the right upper quadrant syndrome. While the most common cause is usually related to gallbladder and biliary tract abnormalities, it’s also essential to emphasize a range of diseases and conditions that may present with similar symptoms but are diagnosed less frequently due to various reasons.

Differential Diagnosis:

1. Drug-induced Liver Injury:
   Diagnosis often involves identifying hepatotoxic drugs. Over 1000 drugs are known to have toxic effects on the liver, typically presenting with mild right upper quadrant pain accompanied by hepatomegaly in two-thirds of patients. Additional symptoms may include fatigue, jaundice, pruritus, digestive disturbances, and acholic stools. Elevated aminotransferase levels, particularly alanine aminotransferase, and other liver function tests aid in diagnosis.
2. Chronic Mesenteric Ischemia (CHD):
   CHD poses a diagnostic challenge due to recurrent abdominal pain not attributable to physical gastrointestinal diseases. Five distinct types of CHD are identified based on clinical manifestations. In cases resembling biliary colic, pain occurs in the right upper quadrant accompanied by nausea and occasional vomiting. Pseudo-tumoral presentations manifest as continuous pain unresponsive to analgesics and progressive weight loss. Imaging techniques such as Doppler ultrasound and angiography play a crucial role in confirming the diagnosis by visualizing arterial stenosis or occlusion directly.
3. Budd-Chiari Syndrome (Hepatic Vein Thrombosis):
   Pain in the abdomen, often localized to the right upper quadrant, is reported in 80% of patients. It may occur in individuals with abdominal trauma, myeloproliferative disorders, paroxysmal nocturnal hemoglobinuria, systemic lupus erythematosus, coagulation factor deficiencies, pancreatic tumors, adrenal, or renal tumors, and hepatocellular carcinoma.
4. Amebiasis:
   Amebiasis, an intestinal infection characterized by ulceration, can manifest chronically with abscess formation in various body parts. While predominantly affecting the liver, it may also present as primary amoebic liver abscess or hepatic amoebiasis. Symptoms include right upper quadrant pain, hepatomegaly, and mild fever. Laboratory tests may reveal leukocytosis.
5. Opisthorchiasis:
   Caused by the parasitic trematode Opisthorchis felineus, opisthorchiasis affects various organs including the biliary passages, pancreas, and liver. Clinical manifestations range from subtle to overt systemic effects. Diagnosis relies on a distinct medical history, local symptoms, leukocytosis, detection of Opisthorchis in stool or duodenal contents, and positive immunofluorescence tests.

Conclusion:
The differential diagnosis of right upper quadrant syndrome encompasses various conditions beyond gallbladder pathology. A systematic approach, including comprehensive medical history, physical examination, and appropriate diagnostic tests, is crucial for accurate diagnosis and management.

Diagnostic Tests for Right Upper Quadrant Syndrome:

• Complete Blood Count (elevated white blood cell count and increased erythrocyte sedimentation rate in acute cholecystitis and exacerbation of chronic cholecystitis).
• Duodenoscopy (motility, concentration, Oddi sphincter muscles, inflammation – mucosa, biliary cells, bile acid reflux, cholesterol).
• Bilirubin, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, amylase, and lipase measurements in blood during or later after 6 hours from the end of the pain episode.
• Ultrasonography.
• Esophagogastroduodenoscopy.

Causes of Right Upper Quadrant Syndrome:

Gallbladder and Biliary Tract Disorders:

• Acute cholecystitis and cholangitis.
• Chronic cholecystitis and gallstones.
• Biliary colic.
• Biliary tract obstruction.
• Biliary sludge.
• Increased cholesterol content in the gallbladder.

Liver Diseases:

• Hepatitis of any cause.
• Drug-induced liver toxicity.

Gastrointestinal and Abdominal Space Problems:

• Budd-Chiari syndrome (hepatic vein thrombosis).
• Perihepatic inflammation (Fitz-Hugh-Curtis syndrome).
• Hepatic amoebiasis.
• Opisthorchiasis infection.

Stomach, Duodenum, and Abdominal Diseases:

• Gastric and duodenal ulcers.
• Acute gastritis.
• Acute gastric dilatation.
• Acute pancreatitis.
• Pancreatic head cancer.
• Appendicitis in the retrocecal area.
• Subphrenic abscess.
• Chronic mesenteric ischemia.

Thoracic and Chest Organ Diseases (Lungs, Heart):

• Lower right lung pleurisy.
• Fractures of the lower right ribs.
• Pulmonary artery thrombosis and pulmonary embolism.
• Chest pain, heart attack, pericarditis.

Other Causes:

• Burns’ hernia.
• Pain related to exercise.
• Premenstrual syndrome.

Pain in Athletes:

In athletes, the mechanism of pain occurrence in the right upper quadrant involves stopping or reducing strenuous physical activities, as reducing pain intensity or stopping physical activity may lead to pain disappearance. Deep breathing exercises and massage in the right upper quadrant area can reduce pain intensity. These measures can be performed directly during physical activity.

Premenstrual syndrome in female athletes may represent another type of disorder appearing in the second phase of the menstrual cycle, characterized by various manifestations of neurological, psychological, vascular, and hormonal disorders. Premenstrual syndrome may sometimes manifest as liver pain.

Source: “Doctors’ Guide” Magazine.