RUQ Pain Masqueraders

Important Extra-Peritoneal Etiologies of RUQ Pain That Require Acute Management

Case

33 yo Hispanic F c no significant PMH presents to the ED c c/o RUQ pain for 3 days.  Patient describes the pain as “stabbing,” with a constant baseline but “waves” of intensification and radiation to her groin.  Pain has been associated with N/V, but none today.  Denies abnormal urinary symptoms or changes in her bowel movements.  Denies chest discomfort.   Denies acute difficulty breathing or cough, but states she was diagnosed and treated (with antibiotics) for “bronchitis” one week ago.  Denies drug/alcohol use.  Has used OTC Advil and Tylenol for pain, with minimal relief.  Patient is uncertain of relation to meals, but does endorse a remote history of postprandial emesis with small amounts of blood (both dark red and black) one month ago.

Vitals on presentation are T 98.8, P 100, RR 16, BP 129/73, SpO2 96% on room air.  Physical exam remarkable for diffuse abdominal TTP worst in the RUQ and mid-epigastric regions, R CVA tenderness and tachycardia.  Deep inspiration is limited 2/2 pain.  CBC, CMP, Lipase, Lactate remarkable only for a slightly elevated WBC of 12.16 and slightly elevated Alk Phos of 124.  UA remarkable for WBC 14, small blood and small leukocyte esterase.  RUQ US remarkable only for hepatic steatosis.

Clinical Question

In the absence of intra-peritoneal pathology, what are other common acute care causes of RUQ pain?

Renal

  • Acute Pyelonephritis
  • Renal Calculus w/ or w/o Hydronephrosis

Patient is treated with IV abx for her presumptive diagnosis of acute pyelonephritis.  CT renal colic negative for calculus or hydronephrosis.   Patient given IV Morphine for pain and Zofran for nausea.  However, after 4mg IV Morphine x2, pain is still not controlled.  After 1mg IV Dilaudid, patient still looks uncomfortable and rates pain as “6/10.”  Patient is now coughing regularly, her pulse is now 104 and she is satting 93% on RA.  #WhatTheHeck?!

Pulmonary

  • Pneumonia
  • Pulmonary Embolism

CXR remarkable for RML and RLL infiltrates, suspicious for pneumonia.  Considering clinical picture and week-old history of “bronchitis” treated with an unknown course of abx, patient is treated empirically for CAP with IV Ceftriaxone and Azithromycin.  Patient denies h/o blood clots, cancer, recent travel, surgery or hospitalization, or OCP use.  However, considering patient’s worsening tachycardia and respiratory status, a D-Dimer was drawn to r/o Pulmonary Embolism.  It came back with a positive value of 0.5.  CTA chest obtained, showing small peripheral RLL PE.   Patient started on SC lovenox and admitted.

References

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