Pain in the right hypochondrium

Specialty: Gastrointestinal.

• Right subcostal pain
• biliary colic
• pain in the upper right abdominal quadrant

Why it occurs

• Biliary colic or acute cholecystitis secondary to stone obstruction of the cystic duct or common bile duct
• Acute hepatitis (viral, alcoholic, autoimmune or toxic) with distention of the liver Glisson's capsule
• Liver abscess (pyogenic or amoebic) with inflammation and focal parenchymal necrosis
• Acute passive hepatic congestion secondary to decompensated right heart failure
• Fitz-Hugh-Curtis syndrome (inflammatory perihepatitis secondary to pelvic inflammatory disease due to Chlamydia or Gonococcus).

Initial workup

Upper abdominal ultrasound (first choice study: highly sensitive to evaluate gallstones, wall thickening >4 mm, pericholecystic fluid and common bile duct diameter) | General analysis: transaminases (AST, ALT), total and fractionated bilirubin, gamma-glutamyl transferase (GGT), alkaline phosphatase, amylase, lipase, blood count and C-reactive protein | Abdominal CT with intravenous contrast if liver abscess or complex biliary complications are suspected | Magnetic resonance cholangioresonance (MRCP) if occult choledocholithiasis is suspected.

Standard management

• Intravenous non-steroidal analgesics — ketorolac 30 mg IV or dexketoprofen 50 mg IV, first line in biliary colic by inhibiting prostaglandins that mediate bile duct contraction
• Direct antispasmodics — butylscopolamine bromide 20 mg slow IV or pargeverine
• Empirical antibiotic therapy in suspected cholecystitis or cholangitis — ceftriaxone 2 g IV every 24 hours combined with metronidazole 500 mg IV every 8 hours, or piperacillin/tazobactam 4.5 g IV every 6 hours
• Ursodeoxycholic acid (for the dissolution of cholesterol microstones in selected non-surgical patients).