What non‑gastrointestinal causes can explain sharp, stabbing right upper quadrant pain in a 47‑year‑old woman?

Non-Gastrointestinal Causes of Sharp Right Upper Quadrant Pain in a 47-Year-Old Woman

In a 47-year-old woman with sharp, stabbing right upper quadrant pain where GI causes have been excluded, you must systematically evaluate for pulmonary, musculoskeletal, cardiac, renal, and gynecologic etiologies, as over one-third of patients initially suspected to have biliary disease actually have alternative diagnoses. 1

Pulmonary and Pleural Causes

Evaluate for lower lobe pneumonia, pulmonary embolism, and pleurisy, as these thoracic conditions frequently refer pain to the RUQ and can be identified on standard RUQ ultrasound or require chest imaging. 1

• Lower lobe pneumonia with diaphragmatic irritation commonly presents as RUQ pain and requires chest radiography or CT for diagnosis 1
• Pulmonary embolism can manifest with pleuritic RUQ pain, particularly when involving the lower lobes, and necessitates CT pulmonary angiography if clinically suspected 1
• Pleural effusion may cause RUQ discomfort and is readily identified on ultrasound examination of the right upper quadrant 1

Musculoskeletal Causes

Consider intercostal muscle strain, rib fracture, costochondritis, and referred pain from thoracic spine pathology, as these are frequently overlooked causes that can be diagnosed clinically or with targeted imaging. 2

• Intercostal muscle strain presents with sharp, stabbing pain that worsens with movement, deep breathing, or palpation of the affected area 2
• Rib fractures (traumatic or pathologic) cause localized tenderness and pain with chest wall compression 2
• Costochondritis produces reproducible pain at the costochondral junctions 2
• Thoracic radiculopathy from nerve root compression can refer sharp pain to the RUQ distribution 2

Renal and Urologic Causes

Evaluate for nephrolithiasis, pyelonephritis, and renal infarction, as right kidney pathology commonly presents with RUQ pain and can be diagnosed with ultrasound or CT. 1

• Nephrolithiasis in the right kidney or proximal ureter causes colicky RUQ pain radiating to the flank and groin, diagnosed with non-contrast CT or renal ultrasound 1
• Acute pyelonephritis presents with RUQ/flank pain, fever, and costovertebral angle tenderness, confirmed with renal ultrasound showing hydronephrosis or perinephric stranding 1
• Renal infarction from thromboembolism causes sudden-onset severe RUQ/flank pain and requires contrast-enhanced CT for diagnosis 1

Cardiac Causes

Rule out acute coronary syndrome and pericarditis, as cardiac ischemia can present atypically as isolated RUQ pain, particularly in women. 2

• Acute coronary syndrome may manifest as epigastric or RUQ pain without classic chest symptoms, especially in women and diabetic patients, requiring ECG and cardiac biomarkers 2
• Pericarditis can cause sharp RUQ pain that worsens with inspiration and improves when leaning forward 2

Gynecologic Causes

In reproductive-age women, evaluate for ovarian pathology including torsion, ruptured cyst, or ectopic pregnancy, even though pain is in the RUQ rather than lower abdomen. 3

• Ovarian torsion or ruptured ovarian cyst can cause referred pain to the RUQ, particularly if there is significant hemoperitoneum tracking cephalad 3
• Ectopic pregnancy with rupture and hemoperitoneum may present with RUQ pain due to blood irritating the diaphragm (though this would typically be associated with lower abdominal findings) 3

Hepatic Non-GI Causes

Consider hepatic vascular pathology, masses, and Fitz-Hugh-Curtis syndrome, as these hepatic conditions are non-gastrointestinal but cause RUQ pain. 1

• Hepatic hemangioma or other benign liver masses can cause capsular stretch and RUQ pain, diagnosed with ultrasound showing characteristic hyperechoic lesion 1
• Hepatic infarction from portal or hepatic vein thrombosis causes acute RUQ pain and requires contrast-enhanced CT or MRI 1
• Fitz-Hugh-Curtis syndrome (perihepatitis from pelvic inflammatory disease) causes sharp RUQ pain in women with history of sexually transmitted infections, diagnosed clinically and with pelvic imaging 1
• Budd-Chiari syndrome (hepatic vein thrombosis) presents with RUQ pain, hepatomegaly, and ascites 1

Adrenal Causes

Evaluate for adrenal hemorrhage or mass, particularly in patients on anticoagulation or with recent trauma. 1

• Adrenal hemorrhage causes sudden severe RUQ pain and can be identified on CT or ultrasound as an enlarged, heterogeneous adrenal gland 1
• Adrenal masses (adenoma, pheochromocytoma, or metastases) may cause RUQ discomfort from mass effect 1

Functional and Visceral Hypersensitivity

Consider irritable bowel syndrome with visceral hypersensitivity, as this was the underlying diagnosis in 21 of 22 patients with chronic RUQ pain in whom extensive workup was negative. 4

• Visceral hypersensitivity from irritable bowel syndrome can manifest as chronic RUQ pain that is reproducible with intestinal distension at trigger sites including jejunum, ileum, right colon, or duodenum 4
• This diagnosis should be considered after thorough exclusion of organic pathology, particularly in patients with longstanding symptoms and multiple negative investigations 4

Critical Diagnostic Algorithm

Order right upper quadrant ultrasound first to evaluate hepatic, renal, and pleural pathology, as this remains the initial imaging modality of choice even when evaluating non-GI causes. 3, 1

• If ultrasound is unrevealing and clinical suspicion remains high, obtain chest radiography to exclude pulmonary causes 1
• For suspected renal pathology with negative ultrasound, proceed to non-contrast CT for nephrolithiasis or contrast-enhanced CT for vascular causes 1
• If cardiac etiology is suspected, obtain ECG and troponin immediately 2
• In reproductive-age women with negative abdominal imaging, obtain pelvic ultrasound to exclude gynecologic pathology 3

Common Pitfalls to Avoid

• Do not assume all RUQ pain is biliary—over one-third of patients initially thought to have acute cholecystitis have alternative diagnoses 1
• Do not overlook pulmonary causes—lower lobe pneumonia and pulmonary embolism frequently present as isolated RUQ pain without respiratory symptoms 1
• Do not dismiss musculoskeletal causes—these are common, easily diagnosed clinically, and often missed because imaging focuses on intra-abdominal organs 2
• Do not forget cardiac evaluation in women—acute coronary syndrome can present atypically as RUQ pain, particularly in women and diabetic patients 2
• Do not ignore functional causes after negative workup—visceral hypersensitivity from irritable bowel syndrome is a real diagnosis that explains chronic RUQ pain in many patients with extensive negative investigations 4