Differential Diagnosis for Right Upper Quadrant Abdominal Pain
The patient presents with right upper quadrant abdominal pain, particularly under the right breast, with radiation to the back and shoulders bilaterally, elevated white count, but normal liver function tests and pancreatic enzymes. Here's a categorized differential diagnosis:
Single Most Likely Diagnosis
- Cholecystitis: Given the location of the pain (right upper quadrant, under the right breast) and the elevated white count, cholecystitis (inflammation of the gallbladder) is a strong consideration. The absence of fever and normal liver function tests does not rule out this diagnosis, as these can be variable in presentation.
Other Likely Diagnoses
- Biliary Colic: Pain from biliary colic can radiate to the back and is typically located in the right upper quadrant. It's often associated with gallstones but can occur without them. The normal liver function tests and absence of fever do not exclude this diagnosis.
- Peptic Ulcer Disease: Although more commonly associated with epigastric pain, peptic ulcers can cause right upper quadrant pain, especially if the ulcer is located in the duodenum near the bile duct entrance. The elevated white count could indicate an ulcer complication like perforation or penetration.
- Pancreatitis: Despite normal pancreatic enzymes, pancreatitis should be considered, especially if the patient has recently eaten a fatty meal or has a history of alcohol use. Some cases of pancreatitis may have normal or only slightly elevated enzyme levels early in the course of the disease.
Do Not Miss Diagnoses
- Hepatic Abscess: Although liver function tests are normal, a hepatic abscess could present with right upper quadrant pain and an elevated white count. It's crucial to consider this diagnosis due to its potential severity and need for prompt treatment.
- Pneumonia (Right Lower Lobe): Referred pain from a right lower lobe pneumonia could mimic abdominal pain, especially if the diaphragm is irritated. The elevated white count supports an infectious process, and pneumonia would be a critical diagnosis not to miss.
- Myocardial Infarction: Although less common, myocardial infarction can present with atypical pain, including right upper quadrant abdominal pain, especially if the inferior wall of the heart is involved.
Rare Diagnoses
- Hepatocellular Carcinoma: While rare and typically presenting in patients with known risk factors (like cirrhosis), hepatocellular carcinoma could cause right upper quadrant pain and an elevated white count due to tumor necrosis or infection.
- Intra-abdominal Lymphoma: Lymphoma involving abdominal lymph nodes could cause non-specific abdominal pain and an elevated white count. This diagnosis would be considered if other more common causes are ruled out and there are systemic symptoms like weight loss or night sweats.