Differential Diagnosis for RUQ Tenderness

The differential diagnosis for right upper quadrant (RUQ) tenderness can be organized into several categories based on the likelihood and potential impact of missing the diagnosis.

• Single Most Likely Diagnosis

  • Gallbladder Disease (Cholecystitis or Cholelithiasis): This is often the first consideration for RUQ tenderness due to the high prevalence of gallstones and the frequency with which they cause symptoms in this area. The pain is typically constant and may radiate to the right shoulder or back.

• Other Likely Diagnoses

  • Peptic Ulcer Disease: Both gastric and duodenal ulcers can cause RUQ tenderness, especially if they penetrate or perforate, leading to peritonitis.
  • Hepatitis: Viral, alcoholic, or drug-induced hepatitis can cause liver inflammation, leading to RUQ pain.
  • Pyelonephritis or Kidney Stones: While these conditions primarily affect the kidneys, they can cause referred pain to the RUQ, especially if the right kidney is involved.

• Do Not Miss Diagnoses

  • Appendicitis (with an atypical presentation): Although appendicitis typically presents with pain in the lower right quadrant, an retrocecal appendix can cause pain in the RUQ.
  • Hepatic Abscess or Liver Mass: These conditions can cause significant morbidity if not promptly diagnosed and treated.
  • Cholangitis: Infection of the bile ducts, which can be life-threatening if not recognized and treated promptly.
  • Pneumonia (right lower lobe): Can cause referred pain to the RUQ due to the proximity of the diaphragm to the lung base.

• Rare Diagnoses

  • Liver Cysts or Hemangiomas: While usually asymptomatic, large liver cysts or hemangiomas can cause RUQ pain if they rupture, bleed, or become infected.
  • Right Adrenal Gland Pathology: Tumors or hemorrhage of the right adrenal gland can cause RUQ pain, though this is exceedingly rare.
  • Intestinal Obstruction or Volvulus: Certain types of intestinal obstruction or volvulus can present with RUQ tenderness, especially if the obstruction involves the small intestine or the cecum.