notes by dr Claudio Italiano
It can be a pain affecting the liver, distension of its lining, glissoniana (stasis liver of heart failure, acute viral hepatitis) but mainly the biliary tract,
that is a "colic" pain.
It is a pain that comes and goes, first it is weak, then increases in intensity, is accompanied by nausea and vomiting and a swollen
feeling of abdomen, and can radiate to the right shoulder, below the scapula.
This is a classic pain from "bilious colic", that is from calculi of the main biliary duct, especially if biliary sludge or other calculations exist in the
gallbladder. And if there is fever, we also think of cholangitis, usually the infection of the biliary tract due to bacterial processes or cholecystitis with
or without obstruction, depending on whether or not jaundice appears.
The pain of the right upper abdomen or of the right hypochondrium, as it is better
technically defined, may also depend on other organs, for example from diseases
affecting the duodenum and the pre-pyloric gastric region, generally referring
to peptic ulcers and gastritis.
This time is a pain felt as "burning" and
related to the meal, in the sense that if it is exacerbated immediately by the
intake of food in the stomach depends on gastric or prepyloric ulcers, if, vice
versa, arises after a few hours from it, it means that depends from ulcers of
the duodenal bulb or from other diseases of the duodenum, including the
diverticula and can always be irradiated posteriorly, to the back, always under
the scapula.
But a pain in the right hypochondrium, perceived as "burning",
especially if it manifests itself also in the epigastrium, that is the area that
the people commonly define "the mouth of the soul", perceived as a feeling of
repetition, associated with nausea and vomiting and even "cramps" and irradiated
"belt", ie all around, even the back, may be due to acute pancreatitis, or the
inflammation of the pancreas that follows a blockage of the main biliary route
by calculations or better microcalcolyzing, with "fire" of the organ due to the
enzymes it is endowed with (lipase, trypsin, chymotrypsin, elastase, etc.).
Other times it follows a large meal or abundant libations (alcoholic
pancreatitis). It is always a serious condition, which can determine the
patient's death if it is not quickly intervened with investigations aimed at
diagnosis and with appropriate therapy. It is also necessary to think of tumors
of the pancreas or the papilla of Vater
Remember always:
the rule of fasting (!)
A patient with abdominal pain, whatever the origin of this pain, must remain fasting (take care of surgical abdominal pain).
- The patient with abdominal pain, whatever its
origin is preferable to remain fasting for os (>> surgical abdominal pain). In
these cases the abdomen becomes initially rimpanic, the pain is sharpened, and
if the doctor tries to visit the patient, he moves the explorer's hand away from
his abdomen.
Sometimes the abdomen becomes tense and contracted, like a table, and the
peristalsis of the hollow viscera is no longer appreciable. The sign of Blumberg
or Murphy may appear. If the doctor who is palpating the abdomen suddenly
releases the hand there may be an intense pain to the rebound, or if the
inflated gallbladder is palpated, it stops the patient's breathing because of
the pain.
- If the patient has these signs, if the peristalsis is absent or if there is
hyperperistaltism, if the alve is closed to feces and gas, always go to the
emergency room and perform instrumental and bio-temporal investigations, start
with a simple radiograph of the abdomen, technically called "RX direct abdomen"
which provides an idea about free air in the abdomen (sign of perforation of
organs) and of hydroaerial levels (signs of surgical abdomen).
Other times the pain of the upper abdomen correlates with a feeling of spasm, like something that swells inside the belly (swollen belly), which runs, like a washing machine and technically the doctors talk about "right flexure syndrome of the colon "or" hepatic flexure ", that is the place where the colon, that is the last part of the intestine, folds after the ascending tract and proceeds in the transverse colon, which in some subjects can be particularly long and festooned, with a peristalsis torpid and laborious.
In these patients gaseous colonic distension can give rise to intense gaseous colic, with sweating and a sense of malaise and even fainting, especially if we are dealing with very sensitive female subjects. If, then, accompanies colic or constipation to constipation and diarrhea, then we will have irritable bowel syndrome.
Not always the pain of the right hypochondrium is due to organs of the digestive system. The writer, for example, visited the other day a 40-year-old woman with a history of calculi of the right kidney, treated with antispasmodics without benefit, who accused serotina fever and pain on the breath, at the height of the lodge renal and along the course of the last rib at the base of the right hematitis.
I had a standard chest X-ray and it was found that the
patient had a right-sided right breast opaque, with exudative pleurisy (see
chest). It was a pain that affected the extra-peritoneal organs the kidney and
the right pleura. The kidney pains, however, from kidney stones, are located at
the back, at the level of the renal lodge and the kidney, is sensitive to the
maneuver of the Jordan, that is to the blow settled with the cutting hand; they
are pains of the colonic type, the renal ones, which radiate along the course of
the ureter to the testis in the man and to the inguinal fold in the woman. They
may depend on simple kidney stones, on hydronephrosis, ie dilation of the kidney
basin following a calculation that obstructs the ureter, renal infarct and
pyelitis or cystopyelitis.
Take care to the pulmonary embolism, characterized by pain radiating from the right hypochondrium simulating the picture of bilious
colic! Finally, also a herpes zoster, along the course of the costal nerve,
which manifests itself with a linear eruption of bullous and painful vesicles,
like fiery pins (Fire of S. Antony) can give pain in the abdominal area. Finally,
remember that even a dissecting aneurysm of the abdominal aorta can begin with a
strange pain to the epigastrium irradiated to the right side!
The diagnosis is based on the clinical suspicion of the disease and is
supported by tests such as:
- Abdominal ultrasound and follow the abdomen CT, the RMN or the Colangio RMN
and an operative ERCP evt, EGDS or colonscopy
- Direct Rx of the abdomen (to evaluate signs of intestinal occlusion and
subocclusion, coprostasis, water levels, leveling, abdominal free air (!!),
ominous sign of bowel perforation)
- Chest X-ray
- The CT abdomen with or without contrast
dolore addome superiore sinistro
dolore addome medio dolore addome inferiore destro
dolore addome inferiore sinistro
Emergenze addominali
