What should be done for a patient experiencing right side abdominal pain?

Right Side Abdominal Pain: Diagnostic and Management Approach

For a patient presenting with right-sided abdominal pain, immediately obtain a pregnancy test in women of reproductive age, followed by ultrasonography as the first-line imaging study for right upper quadrant pain, or CT with IV contrast for right lower quadrant pain. 1, 2, 3

Immediate Assessment and Initial Workup

Essential Laboratory Tests

• Complete blood count (CBC) to assess for leukocytosis indicating infection, inflammation, or appendicitis 1
• Comprehensive metabolic panel (CMP) including liver function tests (ALT, AST, alkaline phosphatase, bilirubin) to evaluate hepatobiliary pathology 1
• Serum lipase (more specific than amylase) if pancreatitis is suspected 1
• Urinalysis to rule out urinary tract infection or nephrolithiasis 1, 2
• Beta-hCG (pregnancy test) is mandatory in all women of reproductive age before any imaging to avoid missing ectopic pregnancy 1, 2, 4

Critical Early Interventions

• Initiate IV fluid resuscitation immediately if acute mesenteric ischemia is suspected to enhance visceral perfusion 5
• Correct electrolyte abnormalities and anemia in patients presenting with acute abdomen 5
• Administer low molecular weight heparin for thromboprophylaxis in inflammatory bowel disease patients with acute abdomen 5

Location-Specific Imaging Strategy

Right Upper Quadrant Pain

Ultrasonography is the initial imaging test of choice with the highest appropriateness rating (9/9) for right upper quadrant pain 5, 2, 4, 3. This modality:

• Provides no radiation exposure, particularly important in young patients 2, 4
• Effectively evaluates gallbladder pathology (cholecystitis, cholelithiasis), liver abnormalities, and hepatobiliary tract disease 5, 2, 4
• Can identify complications such as gallbladder wall thickening, pericholecystic fluid, and stones 5

Second-line imaging options if ultrasound is non-diagnostic:

• Tc-99m cholescintigraphy (HIDA scan) for suspected gallbladder disease with appropriateness rating 6/9 4
• CT abdomen with IV contrast to detect complications like gangrene, perforation, or adjacent liver hyperemia (cannot be seen without contrast) 5
• MRI with MRCP for equivocal cases or when hepatobiliary abnormalities need further characterization 5

Right Lower Quadrant Pain

CT with IV contrast is the recommended imaging modality for right lower quadrant pain to evaluate for appendicitis, diverticulitis, or other pathology 1, 3, 6.

Specific Clinical Scenarios

Suspected Acute Mesenteric Ischemia

Right-sided abdominal pain with passage of maroon or bright red blood is highly suggestive of non-occlusive mesenteric ischemia (NOMI) 5. In critically ill patients requiring vasopressor support:

• Suspect NOMI with unexplained abdominal distension, gastrointestinal bleeding, or new organ failure 5
• CT angiography (CTA) is the diagnostic test of choice to differentiate occlusive from non-occlusive disease 5
• Consider lactate and D-dimer if mesenteric ischemia is suspected, though these lack specificity 1
• Immediate fluid resuscitation with crystalloid and blood products is essential before definitive diagnosis 5

Inflammatory Bowel Disease with Acute Pain

Multidisciplinary management involving gastroenterologist and acute care surgeon is optimal 5. Key management principles:

• Antibiotics should NOT be routinely administered, only if superinfection or intra-abdominal abscess is present 5
• For abscesses: Prompt antimicrobial therapy covering Gram-negative/aerobic bacilli, Gram-positive streptococci, and obligate anaerobes (fluoroquinolones or third-generation cephalosporin plus metronidazole) 5
• Non-drainable abscesses <3 cm without fistula may respond to antibiotics alone, though with high recurrence rates 5
• Clinical improvement should occur within 3-5 days; if not, repeat imaging and consider percutaneous drainage or surgery 5

Chronic/Intermittent Right Upper Quadrant Pain

For an 18-year-old female with intermittent RUQ pain:

• Ultrasonography remains first-line with appropriateness rating 9/9 4
• Particularly valuable for identifying gallbladder disease, the most common cause of intermittent RUQ pain 4
• Obtain pregnancy test first before any imaging 4

Common Pitfalls to Avoid

• Failing to obtain pregnancy testing before imaging in women of reproductive age leads to unnecessary radiation exposure and can miss ectopic pregnancy 1, 2, 4
• Using CT as first-line imaging for RUQ pain in young patients unnecessarily exposes them to radiation when ultrasound is more appropriate 2, 4
• Conventional radiography (plain X-rays) has limited diagnostic value for most abdominal pain and should not be routinely ordered 1, 2
• Relying solely on laboratory tests without appropriate imaging when clinically indicated leads to delayed diagnosis 2, 4
• Routine antibiotic administration in IBD patients without evidence of infection or abscess is not recommended 5

When Urgent Surgical Consultation is Required

• Suspected appendicitis (all patients should be admitted) 6
• Bowel perforation or peritonitis 5
• Failed medical management of IBD with abscess after 3-5 days 5
• Acute mesenteric ischemia with bowel necrosis 5
• Complicated acute cholecystitis with gangrene, perforation, or gas formation 5