Right Hypochondrial Pain: Biliary Pain, Acute Cholecystitis, Dyspepsia, Duodenal Ulcer, Diagnosis and Treatment

Clinically speaking, the symptoms and signs of this region are of great importance and have a specific list of diseases in their differential diagnoses.

In anatomy, the division of the abdomen into regions can use a scheme of nine regions, in which the hypochondrium is the upper part of the abdomen on each side, inferior to (below) the thorax, in the area of ​​the lower ribs, above the level of line with the navel.

The upper right hypochondrium is close to specific organs, including the liver and gallbladder. The liver is in the right hypochondrium, and The spleen and a large part of the stomach area are in the left hypochondrium.

Pain in this part of the abdomen is often associated with disorders that affect these organs.

The most common diseases in the appearance of pain in the upper right hypochondrium are gallbladder stones, responsible for biliary colic pain, hepatitis, or other liver diseases, sometimes painful.

Depending on the suspected cause, biological tests may be performed, such as an ultrasound or a CT scan. Possible causes of pain in the upper right quadrant include:

Biliary pain

Constant, non-paroxysmal pain that increases rapidly lasts four to six hours and occasionally radiates to the right subscapular area.


Biliary colic, also known as gall bladder or gallstone attack, occurs when pain occurs due to a gallstone that temporarily blocks the bile duct.

Usually, the pain is in the upper right of the abdomen and can radiate to the shoulder. The pain usually lasts from one to a few hours. Often, it happens after eating a heavy meal or during the night. Repeated attacks are expected.

However, the presence of gallstones is a frequent incidental finding and does not always require treatment in the absence of identifiable disease.

In addition, biliary pain can be associated with functional disorders of the biliary tract, called acalculous biliary pain (pain without stones). It can even be found in patients after cholecystectomy (removal of the gallbladder), possibly due to the dysfunction of the biliary tract: the biliary tree and the sphincter of Oddi.

Acute episodes of biliary pain can be induced or exacerbated by certain foods, most commonly those with high-fat content.

The formation of gallstones is caused by the precipitation of crystals that aggregate to form stones. The most common form is cholesterol gallstones. Other forms include calcium, bilirubin, pigment, and mixed gallstones.

Other conditions that produce similar symptoms include appendicitis, stomach ulcers, pancreatitis, and gastroesophageal reflux disease.

Treatment for gallbladder attacks is usually surgery to remove the gallbladder. This can be done through small incisions or a single larger incision.

Open surgery through a larger incision is associated with more complications than surgery through small incisions. The surgery is usually done under general anesthesia.

In those who can not undergo surgery, drugs can be tried to dissolve the stones or lithotripsy with shock waves. As of 2017, it is unclear if surgery is indicated for all people with biliary colic.

In today’s world, about 10-15% of adults have gallstones. Biliary colic occurs at 1-4% each year of those with gallstones. Almost 30% of people have more problems related to gallstones in the year after an attack.

About 15% of people with biliary colic eventually develop gallbladder inflammation if they do not receive treatment. Other complications include inflammation of the pancreas.

Acute cholecystitis

Biliary pain of longer duration (more than six hours) with sensitivity, fever, and leukocytosis.

Cholecystitis is inflammation of the gallbladder. Symptoms include upper right abdominal pain, nausea, vomiting, and, occasionally, fever. Often, attacks of the gallbladder (biliary colic) precede acute cholecystitis.

The pain lasts longer in cholecystitis than in a typical gallbladder attack. Without adequate treatment, recurrent episodes of cholecystitis are common. Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, or inflammation of the common bile duct.

More than 90% of the time, acute cholecystitis comes from the blockage of the cystic duct by a gallstone. Risk factors for gallstones include birth control pills, pregnancy, a family history of gallstones, obesity, diabetes, liver disease, or rapid weight loss.

Occasionally, acute cholecystitis occurs due to vasculitis, chemotherapy, or recovery from major trauma or burns. Cholecystitis is suspected according to symptoms and laboratory tests. Abdominal ultrasound is usually used to confirm the diagnosis.

The treatment usually consists of laparoscopic gallbladder removal within 24 hours, if possible. It is recommended to take photographs of the bile ducts during surgery. The routine use of antibiotics is controversial.

They are recommended if the surgery can not happen promptly or if the case is complicated. Stones in the common bile duct can be removed before surgery by endoscopic retrograde cholangiopancreatography or during surgery.

Complications of surgery are rare. You can try draining the gallbladder in people who can not have surgery.

Women have gallstones more often than men and present more often after age 40. Certain ethnic groups are affected with excellent continuity; 48% of American Indians have gallstones.

If left untreated, about 20% of people with biliary colic develop acute cholecystitis. Once the gallbladder is removed, the results are usually good. Without treatment, chronic cholecystitis may occur. The word is from the Greek, collect, which means “gallbladder,” and it is “inflammation.”


Swelling, nausea, belching, intolerance to fatty foods.

Indigestion, also known as dyspepsia, is a condition of altered digestion. Symptoms may include the fullness of the upper abdomen, heartburn, nausea, belching, or upper abdominal pain. People may also experience a feeling of fullness earlier than expected when eating.

Dyspepsia is a common problem often caused by gastroesophageal reflux disease or gastritis. In a small minority of cases, it may be the first symptom of peptic ulcer disease (an ulcer of the stomach or duodenum) and, occasionally, cancer.

Therefore, new-onset dyspepsia not explained in people older than 55 years or the presence of other alarming symptoms may require further investigation.

Functional indigestion (formerly called non-ulcer dyspepsia) is indigestion “without evidence of an organic disease that can explain the symptoms.” It is estimated that functional indigestion affects approximately 15% of the general population in Western countries.

In most cases, the medical history is of limited use to distinguish between organic causes and functional dyspepsia.

An extensive systematic review of the literature was recently conducted to evaluate the effectiveness of the diagnosis of organic dyspepsia by clinical opinion versus computer models in patients referred for upper endoscopy.

Computer models were based on patient demographics, risk factors, historical elements, and symptoms. The study showed that neither the clinical impression nor the computer models could adequately distinguish organic from functional disease.

In a recent study, patients with peptic ulcer disease were compared with patients with functional dyspepsia in a similar age and sex study.

Although the functional dyspepsia group reported more upper abdominal fullness, nausea and increased distress, and general anxiety, almost all of the same symptoms were observed in both groups.

Therefore, the clinician’s challenging task is to separate patients who may have an organic disorder and thus merit further diagnostic testing from patients who have functional dyspepsia, who are given symptomatic empirical treatment.

The study should be aimed at identifying or ruling out specific causes. Traditionally, ” alarm ” characteristics have identified people at high risk. However, the utility of these characteristics in identifying the presence of cancer in the esophagus or upper stomach has been debated.

A meta-analysis analyzing the sensitivity and specificity of alarm characteristics found a range of 0-83% and 40-98%, respectively. However, there was significant heterogeneity between the studies.

The physical examination may cause abdominal tenderness, but this finding is nonspecific. A positive sign of Carnett, or focal sensitivity that increases with contraction and palpation of the abdominal wall, suggests an etiology involving the abdominal wall’s musculature.

The cutaneous dermatomal distribution of pain may suggest a thoracic polyradiculopathy. The sensitivity of Thump on the right upper quadrant may suggest chronic cholecystitis.

Duodenal ulcer

Pain two hours after meals is relieved by taking food or antacids.

Peptic ulcer disease (PUD) is a break in the stomach lining, the first part of the small intestine, or occasionally the lower esophagus. An ulcer in the stomach is called a gastric ulcer, while in the first part of the intestines, it is known as a duodenal ulcer.

The most common symptoms of a duodenal ulcer are: waking up at night with upper abdominal pain or pain in the upper abdomen that improves with feeding. With a gastric ulcer, the pain may get worse with food. Pain is often described as a burning or dull pain.

Other symptoms include belching, vomiting, weight loss, or lack of appetite. About a third of older people have no symptoms. Complications may include bleeding, perforation, and blockage of the stomach. Bleeding occurs in up to 15% of people.

Common causes include the bacterium Helicobacter pylori and non-steroidal anti-inflammatory drugs. Other less common causes include smoking, stress due to serious illness, Behcet’s disease, Zollinger-Ellison syndrome, Crohn’s disease, and liver cirrhosis, among others.

Older people are more sensitive to the effects of the ulcer from non-steroidal anti-inflammatory drugs. Diagnosis is generally suspected due to symptoms that occur with endoscopy confirmation or by ingestion of barium.

H. pylori can be diagnosed by testing the blood for antibodies, a breath test with urea, analyzing the stool for signs of the bacteria, or a stomach biopsy.

Other conditions that produce similar symptoms include stomach cancer, coronary heart disease, inflammation of the stomach lining, or inflammation of the gallbladder.

Diet does not play an essential role in causing or preventing ulcers. Treatment includes stopping smoking, stopping non-steroidal anti-inflammatory drugs, stopping alcohol, and administering medications to decrease stomach acid.

The medication used to decrease the acid is usually a proton pump inhibitor or an H2 blocker with four weeks of initially recommended treatment.

Ulcers due to H. pylori are treated with medications such as amoxicillin, clarithromycin, and a proton pump inhibitor.

Antibiotic resistance is increasing, and, therefore, treatment may not always be practical. Hemorrhagic ulcers can be treated with endoscopy, and open surgery is usually only used in cases where it is not successful.

Peptic ulcers are present in about 4% of the population. In 2015, new ulcers were found in around 87.4 million people worldwide. About 10% of people develop a peptic ulcer at some point.

There were 267,500 deaths in 2015 from below 327,000 deaths in 1990. The first description of a perforated peptic ulcer was in 1670 by Princess Henrietta of England.

H. pylori was first identified as causing peptic ulcers by Barry Marshall and Robin Warren in the late twentieth century, a discovery for which they received the Nobel Prize in 2005.

Liver abscess

Pain associated with fever and chills; palpable liver and subcostal sensitivity.

liver abscess is a mass filled with pus inside the liver parenchyma that results from a bacterial, fungal, or parasitic infection. The infection can spread to the liver through the biliary tree, the hepatic vein, or the portal vein, by extension of an adjacent infection or as a result of trauma.

The common causes are abdominal conditions such as appendicitis or diverticulitis due to hematogenous dissemination through the portal vein.

One or multiple abscesses may be present. A fungal liver abscess can occur in immunocompromised hosts. Amebic liver abscess is a complication of amebiasis.

The leading bacterial causes of a liver abscess include the following:

  • Streptococcal species (including Enterococcus).
  • Species of Escherichia.
  • Staphylococcal species.
  • Species Klebsiella pneumoniae (highest rates of suffering in the Far East).
  • Anaerobes (including Bacteroides species).
  • Species of Pseudomonas.
  • Proteus species.

However, as noted above, many cases are polymicrobial.

There are three primary forms of liver abscess, classified by cause:

  • Pyogenic liver abscess, which is more often polymicrobial, accounts for 80% of cases of liver abscess in the United States.
  • Amebic liver abscess due to the entamoeba histolytica parasite accounts for 10% of cases.
  • Fungal abscess, more often due to Candida species, accounts for less than 10% of cases.

Acute myocardial infarction

Discomfort in the upper right quadrant of the epigastrium; may be similar to biliary pain.

Myocardial infarction (MI), commonly known as heart attack, occurs when blood flow slows or stops in a part of the heart, causing damage to the heart muscle.

The most common symptom is chest pain or discomfort that can travel to the shoulder, arm, back, neck or jaw.

It often occurs in the center or left side of the chest and lasts more than a few minutes. The discomfort may occasionally feel like heartburn. Other symptoms may include shortness of breath, nausea, faintness, cold sweat, or tiredness. About 30% of people have atypical symptoms.

Women have atypical symptoms more often than men. Among those older than 75 years, about 5% have had a myocardial infarction with little or no history of symptoms. A myocardial infarction can cause heart failure, irregular heartbeat, cardiogenic shock, or cardiac arrest.

The majority of myocardial infarctions occur due to coronary artery disease. Risk factors include high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol, poor diet, and excessive alcohol intake, among others.

Complete coronary artery obstruction caused by a ruptured atherosclerotic plaque is usually the underlying mechanism of myocardial infarction.

Myocardial infarcts are less frequently caused by spasms of the coronary artery, which can be due to drugs such as cocaine, significant emotional stress, and extreme cold.

Several tests help diagnose, including electrocardiograms, blood tests, and coronary angiography.

An electrocardiogram, which is a record of the heart’s electrical activity, can confirm an ST myocardial infarction if ST elevation is present. Commonly used blood tests include troponin and, less frequently, creatine kinase MB.

The treatment of myocardial infarction is a critical time. Aspirin is an appropriate immediate treatment for a possible myocardial infarction.

Nitroglycerin or opioids can help with chest pain; however, the overall results do not improve. Supplemental oxygen should be used in people with low oxygen levels or difficulty breathing.

In a myocardial infarction with ST-segment elevation, the treatments try to restore blood flow to the heart and include percutaneous coronary intervention (PCI), where the arteries open and can be a stent, or thrombolysis, where the blockage is eliminated with medicines.

People with myocardial infarction without ST elevation are often treated with heparin-thinning blood, with the additional use of percutaneous coronary intervention in people at high risk.

In people with multiple coronary artery obstructions and diabetes, coronary artery bypass surgery may be recommended instead of angioplasty.

After a myocardial infarction, lifestyle modifications, along with long-term treatment with aspirin, beta-blockers, and statins, are usually recommended.

Worldwide, around 15.9 million myocardial infarctions occurred in 2015. More than 3 million people had a myocardial infarction with ST elevation, and more than 4 million had a myocardial infarction without ST-segment elevation.

ST-segment elevation myocardial infarctions occur approximately twice as long in men as in women. About one million people have a myocardial infarction yearly in the United States.

In the developed world, the risk of death in those with myocardial infarction with ST-elevation is approximately 10%. The rates of myocardial infarction for a particular age have decreased worldwide between 1990 and 2010.