From the Guidelines
A 35-year-old woman with lupus presenting with right upper quadrant (RUQ) pain should undergo abdominal ultrasound as the initial imaging test of choice, as recommended by the American College of Radiology 1. This approach is crucial for promptly evaluating the patient for potential causes of RUQ pain, including lupus hepatitis, autoimmune hepatitis, medication-induced liver injury, and gallbladder disease. The patient's history, physical examination, and laboratory testing, including liver function tests, complete blood count, and lupus activity markers (complement levels, anti-dsDNA), should be thoroughly assessed to narrow down the differential diagnosis. According to the European League Against Rheumatism recommendations, patients with systemic lupus erythematosus (SLE) should be monitored for disease activity, organ damage, and comorbidities, including cardiovascular risk factors and infection risk 1. Given the potential for liver involvement in lupus, it is essential to evaluate the patient for thrombotic complications and to closely monitor disease activity and organ damage. The patient's treatment plan should be tailored to address the underlying cause of RUQ pain, which may involve adjusting immunosuppressive medications, adding corticosteroids, or addressing specific organ complications. Key considerations in the management of this patient include:
- Comprehensive laboratory testing to assess liver function and lupus activity
- Abdominal ultrasound to evaluate for gallbladder disease and assess liver texture and blood flow
- Monitoring for thrombotic complications and close follow-up to adjust treatment as needed
- Assessment of disease activity, organ damage, and comorbidities, including cardiovascular risk factors and infection risk, as recommended by the European League Against Rheumatism 1.
From the Research
Presentation of Lupus with RUQ Pain
- A 35-year-old woman with lupus presenting with right upper quadrant (RUQ) pain may have several possible causes for her symptoms, including gastrointestinal and non-gastrointestinal causes 2.
- Lupus can cause a wide range of systemic manifestations, including liver involvement, which can present with abnormal liver function tests and hepatomegaly 3, 4.
- The categorization of pain in systemic lupus erythematosus (SLE) can be complex, and may involve type 1 and type 2 manifestations, including widespread pain, fatigue, and depression 5.
Possible Causes of RUQ Pain in Lupus
- Rectus sheath hematoma, which can occur spontaneously in patients with SLE, especially during a flare-up of the disease 6.
- Liver involvement, including lupus hepatitis, which can present with elevated liver function tests and hepatomegaly 3, 4.
- Other possible causes of RUQ pain, including gastrointestinal causes such as cholecystitis or peptic ulcer disease, and non-gastrointestinal causes such as musculoskeletal pain or pulmonary embolism 2.
Evaluation and Management
- A thorough evaluation of the patient's symptoms, including history, physical examination, laboratory testing, and diagnostic imaging, is necessary to determine the cause of RUQ pain in a patient with lupus 2.
- Treatment of lupus hepatitis typically involves moderate to high doses of prednisone, and may also involve other immunosuppressive agents such as mycophenolate mofetil 3, 4.
- Management of rectus sheath hematoma typically involves supportive care, including pain management and monitoring for complications such as infection or abscess formation 6.