From the Guidelines
For right upper and lower abdominal pain in a patient with heavy alcohol abuse and negative lipase, the primary differential diagnoses to consider are alcoholic liver disease (hepatitis or cirrhosis) and peptic ulcer disease. Immediate steps should include a comprehensive liver function panel (AST, ALT, ALP, bilirubin, albumin), complete blood count, and abdominal ultrasound, as recommended by the American College of Radiology 1. If liver enzymes are elevated, especially with AST > ALT, this strongly suggests alcoholic liver disease, according to the Kasl clinical practice guidelines for management of alcoholic liver disease 1. In this case, the patient should be counseled on alcohol cessation and started on thiamine supplementation (100 mg IV or IM daily for 3-5 days, then 100 mg orally daily). If liver function tests are normal or only mildly elevated, consider peptic ulcer disease. Initiate empiric treatment with a proton pump inhibitor (e.g., omeprazole 40 mg once daily) and schedule an upper endoscopy to confirm the diagnosis and rule out varices, as suggested by the ACR Appropriateness Criteria for right upper quadrant pain 1. Despite the negative lipase, pancreatitis should still be considered if clinical suspicion is high, as lipase can be normal in chronic pancreatitis or late presentations of acute pancreatitis. Regardless of the specific diagnosis, the patient should be strongly advised to stop alcohol consumption immediately and referred to an addiction specialist for long-term management of alcohol use disorder. Nutritional support and vitamin supplementation (especially B vitamins) are crucial in the management of patients with chronic alcohol abuse, as stated in the guidelines for management of alcoholic liver disease 1. Close monitoring for alcohol withdrawal symptoms is also essential in the acute setting. The use of imaging studies such as ultrasound and MRI can help establish a diagnosis of acute cholecystitis and assess possible alternate diagnoses if acute cholecystitis is not present, as discussed in the ACR Appropriateness Criteria for right upper quadrant pain 1.
From the Research
Differential Diagnosis
The differential diagnosis for a patient with right upper and lower abdominal pain, history of heavy alcohol (ethanol) abuse, and negative lipase (amylase) levels includes:
- Appendicitis, which can present with atypical symptoms due to unusual appendix locations, such as in malrotation 2
- Echinococcal infection, which should be considered in patients with abdominal pain, especially immigrants 3
- Gallbladder fossa abscess, which is a possible complication following cholecystectomy 4
- Intestinal malrotation, which can cause atypical presentations of abdominal pain 2
- Bowel obstruction, which can cause abdominal pain and distension 5
Diagnostic Approach
The diagnostic approach for a patient with abdominal pain should rely on the likelihood of disease, patient history, physical examination, laboratory tests, and imaging studies 5. The location of pain is a useful starting point and will guide further evaluation. For example, right lower quadrant pain strongly suggests appendicitis, while right upper quadrant pain may suggest gallbladder disease or echinococcal infection. Ultrasonography is recommended to assess right upper quadrant pain, and computed tomography is recommended for right and left lower quadrant pain 5.
Special Considerations
Special populations, such as women and the elderly, may present with atypical symptoms of a disease 5. Women are at risk of genitourinary disease, which may cause abdominal pain, while the elderly may present with atypical symptoms of a disease. A high index of suspicion and knowledge of clinical presentations is necessary to achieve early diagnosis and intervention 2.