From the Guidelines
Referred pain from the right upper quadrant (RUQ) to the left upper quadrant (LUQ) of the abdomen is typically caused by diaphragmatic irritation, particularly from conditions affecting the gallbladder, liver, or biliary tract, with acute cholecystitis being the most common cause. The most common cause is acute cholecystitis (gallbladder inflammation), where pain can radiate to the left shoulder or LUQ due to shared innervation through the phrenic nerve 1. Other causes include hepatitis, liver abscess, subphrenic abscess, or pancreatitis. This phenomenon occurs because the diaphragm is innervated by the phrenic nerve (C3-C5), and when irritated on its undersurface by inflammation in RUQ organs, pain signals can be perceived in distant areas sharing the same nerve pathways. Additionally, the extensive autonomic innervation of abdominal organs allows pain to be referred across the midline.
Some key points to consider in the evaluation of right upper quadrant pain include:
- The use of ultrasound (US) as the first choice of investigation for biliary symptoms or right upper quadrant abdominal pain, due to its high accuracy in diagnosing or excluding gallstones 1
- The importance of considering other potential causes of right upper quadrant pain, such as chronic cholecystitis, peptic ulcer, pancreatitis, gastroenteritis, ascending cholangitis, and bowel obstruction 1
- The role of CT imaging in evaluating patients with right upper quadrant pain, particularly in cases where US is negative or equivocal, and in assessing for complications of acute cholecystitis 1
Treatment should target the underlying condition rather than just managing the referred pain. For example, cholecystitis may require antibiotics like piperacillin-tazobactam or ceftriaxone plus metronidazole, pain management with NSAIDs or opioids, and possibly cholecystectomy for definitive treatment. It is essential to note that the choice of imaging modality and treatment approach may vary depending on the specific clinical scenario and the presence of any underlying conditions 1.
From the Research
Referred Pain from Right Upper Quadrant (RUQ) to Left Upper Quadrant (LUQ)
- Referred pain is a type of pain perceived at a location other than the site of the painful stimulus [@\1@, @\2@].
- The causes of referred pain from the RUQ to the LUQ are not explicitly stated in the provided studies, but several studies discuss the causes of pain in the RUQ and the importance of considering multiple organ systems when evaluating abdominal pain [@\1@, @\3@, @\4@, @\5@].
- Some possible causes of pain in the RUQ that may be referred to the LUQ include:
- Acute cholecystitis [@\1@, @\3@, @\4@]
- Choledocholithiasis [@\2@]
- Acute appendicitis, especially in cases of congenital anomalies such as renal agenesis [@\5@]
- Other conditions affecting the hepatic, pancreatic, adrenal, renal, gastrointestinal, vascular, and thoracic systems [@\3@]
Diagnostic Evaluation
- Ultrasound (US) is the primary imaging modality for assessing acute RUQ pain [@\1@, @\3@, @\4@].
- Computed Tomography (CT) may be used to confirm the extent and nature of complications or to evaluate for acute nongallbladder abnormalities [@\1@, @\4@].
- Magnetic Resonance Cholangiopancreatography (MRCP) and Endoscopic Retrograde Cholangiopancreatography (ERCP) may be used in specific cases, such as complicated ductal disease or biliary intervention [@\1@, @\2@].