Right%20Upper%20Quadrant%20Pain%20

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Right Upper Quadrant Pain Mass
Supervisor Dr. Faisal Al Saif.
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DDX

• Gallstones.
• Acute cholecystitis.
• CA of gallbladder.
• Liver tumors.
• Liver abscess and cyst.

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- Severe RUQ Pain- Constant (Not Colicky)-
Fever- Ve Murphys Sign Pt Will Stop
Breathing In Deep Inspiration.- Increase WBC -
Minor Elevation Of LFT- Bilirubin Is Normal.
(Why)- no jaundice

• Acute Cholecystitis

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US Is Initial Study Of Choice In Most Patient
With Biliary Disease Both Sensitivity And
Specificity Are 95 The Wall Of GB Is
ThickenedPericholecystic Fluid.(Appearing Black)
Radiological Murphy's Sign (Put The US Prop
Instead Of Ur Finger)  HIDA scan A Substance
Injected Intravenously Will Be Taken By The Liver
And Excreted As Bile Through The Common Bile Duct
To Reach GB So, When The GB Is Absent In The Scan
We Can Diagnose It As Acute Cholecystitis 

• Diagnosis

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- NPO - Analgesia- Antibiotics-
Cholecystectomy Onset Of Symptomsgt 72 Hours
Immediate Surgery Onset Of Symptoms lt 72 Hours
Surgery Is Delayed For 4-6 Wks

• Treatment

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GALLBLADDER TUMORS

• Benign tumors
• They are rare.
• Papilloma.
• Adenomyoma.
• Fibroma.
• Lipoma.
• myoma.
• myxoma, and carcinoid.

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• Malignant tumors
• Carcinoma of the gallbladder.
• 4 of all carcinomas of the gallbladder. It is
  the most common cancer of the biliary tract

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CARCINOMA OF THE GALLBLADDER

• 90 of the patients have cholelithiasis.
• About 80 of the tumors are adenocarcinomas.
• Metastases occur by lymphatic spread to the
  pancreatic, duodenal, and choledochal nodes and
  by direct extension to the liver.

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• RISK FACTORS
• Gallstones large gt small.
• Porcelain gallbladder.
• Cholecystenteric fistulas.
• IBD
• Mirizzi syndrome

• Porcelain gallbladder intramural calcification
  of the galbladder wall
• Prophylactic cholecystectomy is recommended
• Mirizzi syndrome refers to common hepatic duct
  obstruction caused by an extrinsic compression
  from an impacted stone in the cystic duct

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• CLINICAL PRESENTATION
• Found incidentally at the time of
  cholecystectomy.
• Right upper quadrant pain.
• Jaundice and symptoms secondary to metastasis.
• Associated with nausea and vomiting.

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• TREATMENT
• If there is microscopic invasion of the
  gallbladder, cholecystectomy with wedge resection
  of the liver and regional lymphadenectomy may
  improve the survival.
• Adjuvant chemotherapy is ineffective.
• Radiation therapy is used to reduce tumor size
  and relieve jaundice.
• 5-year survival rate is 0-10.

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TUMORS OF THE LIVER
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HEPATOCELLULAR CARCINOMA

• Most common primary tumor in the liver.
• Incidence is 6 cases per 100,000.
• Affects males more ,male female ratio 21.
• Average age is 50 years old.
• Hepatocellular carcinoma occurs as a solitary
  mass or as multiple masses.

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• Local invasion, especially into the diaphragm, is
  common, as are distant metastases with the lung
  being most commonly involved.

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• RISK FACTORS
• Chronic HBV and HCV.
• Cirrhosis.
• Metabolic disorders.
• Schistosomiasis.
• Environmental toxins.

• Polychlorinated biphenyls.
• Aflatoxins.
• Thorotrast.

• Alpha 1 anti tyrpsin deficiency.

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• CLINICAL PRESENTATION
• Large lesions presents with a dull pain in RUQ
  malaise, fever,anorexia,weight loss and jaundice
  may be found.
• On examination there will be hepatomegaly(88),ten
  der abdominal mass(50),weight loss(85)associated
  with cirrhosis(60).

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• HOW TO DIAGNOSE
• Alpha-fetoprotein increased in 75.
• Hepatic ultrasound
• Not sensitive in lesions less than 2cm.
• CT scan With contrast.
• MRI

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• TREATMENT
• Surgical treatment includes resection and
  transplantation.
• Chemotherapy . Not given systematically.

not given systematically
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• Combination therapy using chemoembolization and
  local ablation may be palliative for patients
  with unresectable lesions.
• Ablative therapies include instillation of
  absolute ethanol into the lesion or insertion of
  a probe and delivery of radio frequency energy
  into the lesion.

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CHOLANGIOCARCINOMA

• a tumor that arises from the bile duct
  epithelium it represents 530 of all primary
  hepatic malignancies.
• In most of patient it discovered incidentally.

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• CLINICAL PRESENTATION
• Right upper quadrant pain, jaundice,
  hepatomegaly, and occasionally a palpable mass.
  Patients are usually 6070 years of age.
• Metastasis occurs initially to the regional lymph
  nodes or to the liver.

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Risk factors
include parasitic infections (e.g., Clonorchis
sinensis), primary sclerosing cholangitis, or
Thorotrast exposure.
Treatment

• of intrahepatic tumors is resection when
  feasible. Overall survival is poor.

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• DIAGNOSIS
• CT will show large hypovascular tumor with
  central necrosis.

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METASTATIC TUMORS OF THE LIVER

• liver is the second most common site of
  metastasis (exceeded only by regional lymph
  nodes) for all primary cancers of the abdominal
  viscera.
• 60 of colorectal cancer.
• 50 of cancers outside the abdomen.
• 30 of all cancers ultimately spread to the
  liver,

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• which is the most common site of hematogenous
  spread.
• Also from pancreas, breast, neuroendocrine and
  urogenital cancer.

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HEMANGIOMA

• Presentation
• Most common benign tumor 7-20 .
• Usually asymptomatic .
• May Present with symptoms of compressing adjacent
  structure or stretching the liver capsule .
• Right upper quadrant pain and mass and bruit.
• There may be single or multiple masses .
• Occur in female more than in male 31 .

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• INVESTIGATION
• U/S .
• CT with IV contrast .
• Tagged RBC scan .
• MRI .
• Biopsy may cause hemorrhage .
• CT WITH IV CONTRASTDURING THE ARTERIAL PHASE
  ,THE TUMOR APPEARS AS A SHARPLY DEFINED MASS WITH
  SEQUENTIAL GLOBAL OPACIFICATION FROM OUTSIDE IN
  .

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Giant cavernous hemangioma of the liver
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• MANAGEMENT
• Observationgt 90 .
• Surgical resection if there is symptoms or
  hemorrhage .

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HEPATOCELLULAR ADENOMA

• Presentation
• Female gt male ( 91 ) between 30 35 years of
  age .
• Associated with OCP and androgenic steroids .
• Usually asymptomatic .
• 25 have RUQ pain and mass .
• Usually single but can be multiple in 30 of
  cases .
• 30 present with spontaneous rupture and
  hemorrhage .
• Risk of developing carcinoma .

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• INVESTIGATION
• LFT normal .
• U/S .
• MRI with gadolinium enhancement .
• CT scan .
• Biopsy normal hepatocyte without bile duct .
• CONTRAST ENHANCED CTDEMONSTRATE MODERATE
  ENHANCEMENT DURING THE ARTERIAL PHASE SHOWS A
  NEARLY HOMOGENEOUS, WELL-ENCAPSULATED MASS

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CT
MRI
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• MANAGEMENTStop OCP,
  avoid pregnancy .
• Observation
• Small , intrahepatic associated with OCP use .
• Surgical resection
• Large gt5cm , superficial , women anticipates
  pregnancy near .

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SPONTANEOUS RUPTURE WITH HEMORRHAGE
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FOCAL NODULAR HYPERPLASIA

• Presentation
• Female gt male approximately 40 years of age .

• Associated with OCP .
• Usually asymptomatic .
• 10 have RUQ pain and mass .
• Single or multiple lesion with nodular appearance

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• INVESTIGATION
• U/S .
• Contrast enhanced CT .
• MRI with gadolinium enhancement .
• Technetium 99m-labeled sulfur colloid scan .

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• Biopsy

The tumor contain hyperplastic hepatocyte with
inflammatory cells and bile duct epithelium .
CONTRAST- ENHANCED CTAPPEARS AS HOMOGENOUS
HYPER ATTENUATING IN ARTERIAL PHASE WITH CENTRAL
SCAR AND RADIATING BANDS
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MANAGMENT

• stop OCP .
• Observation .
• Surgical resection or embolization .

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Liver abscess and cysts

• Bacterial

• Parasitic

• Fungal

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• Source
• Direct spread from biliary tract infection .
• Portal spread from GI infection .
• Systemic infection .
• Liver trauma .
• 10-50 Cryptogenic .

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• PRESENTATION
• RUQ pain and mass .
• Tenderness over RUQ .
• Systemic symptoms
• Fever , chills , sepsis , malnutrition ,
  anemia .

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• INVESTIGATION
• CBC anemia , lukocytosis .
• LFT raised liver enzymes mainly alkaline
  phosphatase .
• Indirect heamgglutination antibody test for
  parasite .
• U/S .
• CT .

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• MANAGEMENT OF BACTERIAL ABSCESS
• IV antibiotics .
• Pericutanous drainage with CT or U/S guidance .
• Surgical operative drainage is indicated for
  multiple abscess or multiple pericutanous
  drainage have failed

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HYDATID CYST

• Result from infection with the parasite
  echinococcus granulosus .
• Dogs are the definitive host shedding ova in the
  feces which infect intermediate host such as man
  , sheep , cattle .
• Endemic infection .

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• May progressively enlarged and ruptured
• 50 within hepatic parenchyma form daughter cysts
  .
• Bile duct debris cause biliary obstruction .
• Peritoneal cavity urticaria , esinophilia ,
  anaphylactic shock .

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MANAGEMENT IV antibiotics (metronidazole )
followed by surgical resection which done by
Surgical drainage then residual space is
sterilized with scolicide agent unless the
aspirate is bilious which mean there is biliary
connection then the cyst is removed .
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