Differential Diagnosis
The patient's symptoms of sudden right lower abdominal pressure that rolls up to the right upper quadrant, feeling like a lump or bulge, and then resolves, can be approached by considering the following categories:
- Single most likely diagnosis
- Gallbladder disease (e.g., biliary colic): The symptoms of intermittent, severe pain in the right upper quadrant, radiating from the lower abdomen, are classic for gallbladder disease. The mild fatty infiltration of the liver seen on sonogram does not directly explain the symptoms but is a common finding and does not rule out gallbladder pathology.
- Other Likely diagnoses
- Gastroesophageal reflux disease (GERD): Although the primary symptom is abdominal pressure, GERD can cause upper abdominal discomfort that might be perceived as pressure or a lump, especially if it involves the right upper quadrant.
- Peptic ulcer disease: Ulcers in the duodenum or stomach can cause severe, episodic pain that might be felt in the right upper quadrant, especially if the ulcer is located in the duodenum.
- Hepatic flexure syndrome: This condition involves intermittent obstruction of the hepatic flexure of the colon, which can cause right upper quadrant pain and a sensation of a lump or fullness.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Acute cholecystitis: Inflammation of the gallbladder, which can be life-threatening if not treated promptly. The symptoms could be an early sign, and the lack of findings on sonogram does not rule out this condition.
- Hepatic or renal tumor: Although rare, a tumor in the liver or kidney could cause intermittent, severe pain and should be considered, especially if other diagnoses are ruled out.
- Pulmonary embolism: In rare cases, a pulmonary embolism can cause referred pain to the right upper quadrant, especially if the embolism involves the right lung.
- Rare diagnoses
- Intermittent torsion of a wandering liver or other abdominal organ: This is an extremely rare condition where an organ twists intermittently, causing severe pain that resolves when the torsion resolves.
- Right diaphragmatic irritation or eventration: Abnormalities of the diaphragm can cause intermittent pain and a sensation of pressure under the ribs, though this would be an unusual presentation.