Acute and Chronic Right Upper (RUQ) Abdominal Pain – Diagnosis

A cause of right upper abdominal pain (also known as right upper quadrant or RUQ pain) may be suspected from its duration, relation to meals, medicines, breathing, body movements and accompanying symptoms.

In this article disorders that cause pain only or mainly in the upper right abdomen are described.

ACUTE Right Upper Abdominal Pain

Acute (sudden, newly appearing) pain in the right upper abdominal quadrant (RUQ) may arise from:

1. Gallstones

Gallstones in the gallbladder typically causes:

  • No symptoms in most cases
  • Cramping pain below the lower right rib (biliary colic) appearing shortly after a heavy meal, lasting from several minutes to several hours and often radiating into the upper back or right shoulder
  • Nausea or vomiting (only sometimes and only together with pain)
  • Jaundice, fever or chills usually appear only when the common bile duct is blocked

Gallstones are rare in children.

Diagnosis. Ultrasound can detect stones over 2 mm in size. When ultrasound shows nothing but gallstones are still suspected, CT, a special MRI or ERCP may be tried. Blood leukocytes in gallbladder gallstones are usually normal, but they are often elevated when a main bile duct is obstructed. HIDA scan can be done, when stones in the common bile duct are suspected.

2. Disorders in the Right Kidney

Inflammation of the kidney tissue – glomerulonephritis due to reaction to bacterial (streptococcal) infection of the throat or certain medications, and kidney infection (pyelonephritis) of the right kidney may result in:

  • Pain and tenderness below the lower right rib in the back or on the right side of the upper abdomen
  • Fever
  • Swelling of the face in the morning or swelling all over
  • Burning pain during urination, changed color and smell of the urine
  • Reduced urination

Diagnosis. Ultrasound may show inflammation of the kidney. Blood test usually show elevated white blood cells. Urine test may show elevated white and red blood cells and proteins (in glomerulonephritis) and bacteria (in pyelonephritis).

Urinary stones in the right kidney or in the upper part of the right ureter may cause sharp intense cramping pain in the right flank, sometimes radiating toward the groin and right inner thigh and lasting from several minutes to an hour. Burning during urination and blood in the urine may be present. Diagnosis is with CT and urine tests.

Urinary stones are rare in children.

3. Hepatitis

Viral hepatitis may cause:

  • Pain, feeling of fullness below the right lower rib
  • Jaundice
  • Pale stool and dark urine
  • Nausea
  • Low grade fever
  • Liver enlargement and tenderness

Diagnosis. Blood tests show antibodies and antigens specific for hepatitis A, B, C, D or E; liver enzymes are elevated.

4. Infectious Mononucleosis (Mono)

Infectious mononucleosis, an infection caused by Epstein Barr virus (EBV), may cause RUQ pain due to liver enlargement. Other typical symptoms are sore throat, enlarged lymph nodes, fever and fatigue. Diagnosisof acute infection is by finding EBV IgM antibodies in the blood.

5. Other Acute Liver Disorders Causing RUQ

Liver abscess, liver amebiasis, toxic hepatitis (in poisoning), hemolytic anemia or other liver disorders may cause RUQ pain.

6. Adrenal Gland Disorders

Infarct of the adrenal gland and pheocromocytoma may cause strong RUQ pain. Diagnosis is with CT or MRI.

7. Pneumonia

Bacterial pneumonia affecting the right lung usually causes:

  • Right side chest and (sometimes) upper right abdominal pain
  • Sweating due to high fever
  • Prominent tiredness
  • Cough with yellow/green mucus
  • Rapid breathing and heart beat
  • Bluish lips

Diagnosis. X-ray of the chest shows a white shadow over affected lung lobe. Blood test shows highly elevated white blood cells. Microbiological investigation of the mucus reveals bacteria.

8. Pleurisy

Pleurisy (pleuritis) is an inflammation of the membranes that cover the lung – due to infection (flu, pneumonia, tuberculosis, injury and so on), autoimmune disease (rheumatoid arthritis, SLE) or pulmonary embolism. Main symptoms:

  • Chest (and eventual upper abdominal pain) during inhaling and exhaling or sneezing and coughing but almost no pain between breaths.
  • Shortness of breath
  • Dry cough
  • Fever or chills (not always)

Diagnosis may be often concluded from symptoms; if not, a special X-ray or CT may be performed.

9. Injuries

Strained or ruptured abdominal wall muscle (common in athletes), a hit or stitch usually cause abdominal pain that worsens with breathing, stretching of the upper part of the body or moving. Abdominal wall is tender to the touch and bluish discoloration and small bulge may appear due to hematoma that builds within the muscle.

Fracture of one or more of the lower right ribs may cause RUQ pain triggered by breathing and changes of body posture. Diagnosis is with an X-ray of the chest.

10. Shingles

Shingles refers to painful rash appearing over the course of one or more of the nerves that  flow from the chest part of the spinal cord toward the abdominal wall, usually only on one side of the body. Sometimes only pain, without the rash, is present. The cause is reactivation of a Herpes zoster virus from previous infection with herpes virus. Diagnosis is by physical examination.

11. Abscess Under the Diaphragm

Some weeks after abdominal surgery, laparoscopy, Cesarean section, appendicitis, injury or perforation of an abdominal organ, a collection of pus (abscess) can develop under the right part of the diaphragm (subphrenic abscess) causing RUQ, right chest or right shoulder pain, fever, cough and shallow breathing. Diagnosis is by an X-ray and ultrasound.

CHRONIC Right Upper Abdominal Pain

Long term (chronic, recurring) pain in the right upper quadrant (RUQ) may arise from:

1. Gallbladder and Bile Duct Disorders

Gallbladder or bile duct stones, cancer, blockage of the bile duct after chronic bile duct inflammation may all cause recurring cramping pains in the upper right abdomen.

Biliary dyskinesia. When no gallstones or other organic changes can be found in the gallbladder or the bile ducts, motility disorders like biliary dyskinesia or “sphincter of Oddi dysfunction” are the possible cause of upper right abdominal pain. Diagnosis is made by special MRI or with measuring pressures in bile duct during upper endoscopy.

2. Liver Disorders

Fatty liver, chronic viral hepatitis, liver cirrhosis and congestive heart failure may all cause chronic RUQ pain, nausea and jaundice. Blood tests (liver panel) and abdominal ultrasound are needed for diagnosis.

Liver cancer or metastases, lymphoma and leukemia appear with above mentioned symptoms and poor appetite, fatigue and weight loss. For diagnosis blood tests, CT, MRI and often liver biopsy are required.

3. Atypical Pneumonia

“Walking pneumonia”, caused by viruses, mycoplasma or rickettsiae, affecting the right lung may cause:

  • Vague right side chest or upper abdominal pains
  • Low grade fever
  • Dry cough
  • Tiredness, feeling unwell

Diagnosis. Chest X-ray shows scattered white patches over the affected lobes. Blood tests may give different results depending on the cause.

4. Chronic Pleurisy

Chronic pleurisy may be caused by asbestosis, silicosis, tuberculosis, mesothelioma, lung carcinoma, etc. Symptoms are like in acute pleurisy (see above).

5. Stomach, Duodenal and Pancreatic Disorders

Disorders of the stomach, duodenum and pancreas that usually cause upper middle abdominal pain may sometimes cause pain in the upper right abdominal quadrant.

6. Cancer

Cancer or metastases in the liver, gallbladder, stomach or pancreas may cause RUQ pain. Loss of appetite and weight loss are common symptoms.

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