One of the most common types of ultrasound studies isevaluation of the right upper quadrant, henceforthreferred to as the RUQ. The other quadrants are surely jealous, as the RUQ is the only one to have a namesake imaging study. But the RUQ looms large for a reason—several reasons, actually.Before we get to that, some of you may be asking…
…”the right up quadrant of what, exactly, good sir?”
Well, imagine youhave fallen asleep at a frat party and your good friend Connordecided to draw on your abdomen with a permanent marker. Connor was neither too mean nor particularly creative, and drewvertical and horizontal lines intersectingat your belly button. The four roughly rectangular regions created by this cross form the four quadrants of the abdomen. You get a gold star if you guessed the right upper quadrant isthe upper one on the right.
Let’s see what’s behind quadrant number one!
The gallbladder, which liesinside the RUQ of yourabdominal cavity, is acommon cause of abdominal pain. While much abdominal pathology isbetter evaluatedwith CT, the gallbladder is particularly well seenwith ultrasound.
Other structures routinely evaluated on RUQ ultrasound include the pancreas, liver, bile ducts, and right kidney. Thefirst three structures—along withthe gallbladder—have close functional and anatomic relationships to each other (see illustration below). Parts of the stomach, small bowel, and colon also extend into the RUQ, but these structures are usually difficult to evaluate with ultrasound (because they contain air) and not routinely imaged onRUQ ultrasound.
Why do I need all these organs?
Before we addressproblems that can occur in the RUQ, it is first necessary to understand the normal anatomy and function of the underlying structures. The liver, gallbladder, bile ducts, and pancreas help withdigestion. Apologies in advance to thehepatologists (liver doctors) out there; ifIoversimplify too much, I’ll buy you a drink.
One of the functions of the liver—a large organ occupying much of the RUQ—is bile production. Bile helps to digest food, and needs to getfrom the liver to the first part of the small intestine, where it doesits job. Bile ducts start as small branches throughout the liver—like tributaries of a river—and combine as they exitthe liver to form first the common hepatic duct and, further down, the common bile duct. The common bile duct dumps into the small intestine at a place called the ampulla of Vater (yes, that’s a real thing).
Bile is also stored in the gallbladder, a sac-like structure beneath the liver which connects to the side of the common bile duct. After a meal, the body may need more bile than the liver can immediately produce, and the gallbladder contracts to push more bile into the common bile duct and small intestine.
The pancreas produces enzymes—amylase and lipase—to aid in digestion, and also excretesbicarbonate (i.e.baking soda) to neutralize stomach acid. The pancreas spansthe middle of the upper abdomen just below the sternum, but part of it—called the head—extends into the RUQ. Pancreatic juices collect in branching ducts (analogous to bile ducts in the liver) and drain viathe main pancreatic duct through that sameampulla of Vater (my favorite ampulla) into the small intestine.
The right kidney just happens to be in the neighborhood of the RUQ, but is not involved in digestion. Kidneysfilter blood to produce urine, andproblems with the right kidney can also cause RUQ pain.
When bad things happen to good gallbladders
Our magicaljourneythrough the RUQ now complete, let’s find out what happens when we throw some wrenches into the system.
- Gallstones and Cholecystitis:The most common culprit behind RUQ pain isthe gallbladder, that worthless sac of bile causingmore trouble than it’s worth sometimes (sorry, gallbladder, the truth hurts). Two related and sometimes coexisting abnormalities affecting the gallbladder are gallstonesandacute cholecystitis.
- Gallstonesare stones that form inside the gallbladder, in part due to imbalances in cholesterol and bilirubin (a pigment which gives bile its yellowish color). Too much cholesterol=formation of cholesterol gallstones. Ditto with bilirubin.Bile sittingaround in the gallbladder too long is also felt to contribute to gallstone formation. Gallstones appear bright (echogenic) on ultrasound, and a shadow often projects behind them because they block the ultrasound beam.
- Stones inside your body are never good, and gallstones are no exception. Acute cholecystitis—inflammation of the gallbladder—occurs most commonly when a gallstone becomes lodged near the gallbladder neck, where it connectsto the common bile duct. This obstructs the ability of the gallbladder to empty; the wall becomes thickened and inflamed, and the patient will often experience a jolt of pain when the ultrasound tech scansover the gallbladder. Acute cholecystitis can more rarely occur when no gallstones are present.
- Gallstones can sometimes pass into the common bile duct and get stuck near the ampulla of Vater, obstructing both the common bile duct and the pancreatic duct. Obstructing the common bile duct canback up the entire biliary system and prevent the normal excretion of bile. Radiologistsmeasure the diameter of the common bile duct, and anything more than 6mm could mean itis obstructed. Bilirubin—a byproduct of the break down of red blood cells by the liver—is normally excreted in the bile. When the common bile duct is obstructed, bilirubin builds up in the blood and causes jaundice, a yellowish discoloration of the skin and whites of the eyes.
- Pancreatitis: If a gallstone blocks the pancreatic duct, pancreatic enzymes backup and the pancreas can actually start to digest itself (!), manifested aspancreatitis, or inflammation of the pancreas. Pancreatitis is usually better evaluated on CT, but we can sometimes see evidence—such as fluid around the pancreas—on ultrasound. A variety of other random funthings can cause pancreatitis, my favorite being the sting of a scorpion.
- Cysts:Cysts—focal collections of fluid—occur in the RUQ, most commonly in the liver and kidney. Cysts are well characterized on ultrasound, which is often used to troubleshoot suspected cysts that were initially seen on CT or MRI.
- Fatty Liver:If you have ever hadfois gras, you have eatenfatty liver of a goose or duck. Humans get fatty livers too; perhaps Hannibal Lecter knows if “humain fois gras” is any good (see footnote for bonus “Silence of the Lambs” medical trivia). Fatty liver occurs when lipids, particularly triglycerides, accumulate in liver cells. Itis often idiopathic, meaning we don’t know what caused it, but other causes includealcoholism, diabetes, and obesity. On ultrasound, a fatty liver looks diffusely bright (echogenic). Interestingly, this condition is reversible if the factor causing it can be removed.
- KidneyAbnormalities:I discussed bleeping renal cystsin another post, so I won’t go into more detail other than to say they are common. Two additional abnormalities that can be seen in the kidney on ultrasound arehydronephrosis andkidney stones.
- Hydronephrosis: As the kidneys filter blood, urine is produced and collects in the central part of each kidney, then flowsthrough thin tubes called ureters down to the urinary bladder.If this drainage system becomes blocked, most commonly by a kidney stone, the resulting dilation can be seen on ultrasound.
- Kidney stones: Also known as renal calculi, kidney stones are common and can cause acute symptoms if they move into the ureters. On ultrasound, they are usually echogenic and produce a shadow, similar to gallstones. Very small stones—less than about 3mm—can be difficult to see on ultrasound, and CT is a better option if small stones are suspected.
- Cancer:Discovering cancer in one of the organs of the RUQ is fortunately arare occurrence. The biliary system can become obstructed by cancers in thehead of the pancreas or in the biliary system itself. Just like when a gallstone blocks the common bile duct, cancers can dilate the biliary system and cause jaundice. Different types of cancer can occur away from the biliary system as well, involving any of the organs in the right upper quadrant.
Other rare and unusualthings show up in the RUQ, but they need to fill medical textbooks with something, so I will stop here.I hope you enjoyed the whirlwind tour through what is, in my opinion, the best quadrant of the abdomen (shh, don’t tell the appendix).
Questions? Comments? Please post below!
1. Hannibal Lecter’s famous quote, “I ate his liver with some fava beans and a nice chianti,” is actually a nerdy psychiatry joke. Monoamine oxidase inhibitors (MAOIs), some of the first antidepressants developed, work by increasing blood levels of tyramine, an amino acid. However, if tyramine levels rise too high, it can dangerously increase blood pressure, so one who takes MAOIs needs to limit foods that are high in tyramine. Guess what foods are famously high in tyramine? Liver, fava beans, and wine. So when Lecter says his famous line, some think he is indirectly telling us that he is not taking his MAOIs.
Right Upper Quadrant
Organs found in this quadrant include: the liver, the gallbladder, duodenum, the upper portion of the pancreas, and the hepatic flexure of the colon. Pain in the right upper quadrant may be indicative of hepatitis, cholecystitis, or the formation of a peptic ulcer.
Upper right abdominal pain, or sharp pain below your ribcage, can be caused by gallstones, a gall bladder infection, a stomach ulcer, hepatitis, pancreatitis, or it may be a lung condition.When should I worry about upper right quadrant pain? ›
If you've had RUQ pain for a week or longer, you should make an appointment to see a doctor. If you experience signs of a medical emergency, like severe pain that lasts longer than a few hours or fever, in addition to RUQ pain, you may need emergency medical attention.How do you check for right upper quadrant pain? ›
The initial imaging tests in patients with RUQ pain should be radiographs of the chest and abdomen. These are rapid and inexpensive ways of evaluating the patient for pul- monary and intestinal sources of pain. In addition, abdom- inal radiographs can detect calcifications in the kidney, ureter, appendix, and pancreas.What cancers cause right upper quadrant pain? ›
Gallbladder tumor can cause a tender, irregularly shaped mass in the right-upper quadrant. Hydronephrosis (fluid-filled kidney) can cause a smooth, spongy-feeling mass in one or both sides or toward the back (flank area). Kidney cancer can sometimes cause a smooth, firm, but not tender mass in the abdomen.What organ could be affected if I have pain at right upper quadrant of abdomen? ›
The right upper quadrant of the ribs covers the pancreas, right kidney, gallbladder, liver, and intestines. Pain under the ribs in this area can indicate a health problem affecting one of these organs.How do you get rid of right upper quadrant pain? ›
- Over-the-Counter (OTC) Medications and Gas and Indigestion. ...
- Anatacids and Other Treatments for Gastritis. ...
- Treat Other Symptoms of Viral Gastritis. ...
- Analgesics and Surgery for Appendicitis. ...
- NSAIDs and Other Medications for Gallstones.
It manifests in different ways, but a common form is a dull throbbing. For some people, it occurs as a sharp, stabbing pain.What does pancreatic pain feel like? ›
The main symptom of acute pancreatitis is a severe, dull pain around the top of your stomach that develops suddenly. This aching pain often gets steadily worse and can travel along your back or below your left shoulder blade. Eating or drinking may also make you feel worse very quickly, especially fatty foods.What is the pain under the ribs on the right side? ›
Conditions that affect the gallbladder cause pain under the ribs on your right side because that is where the gallbladder is located. The gallbladder stores bile, which is necessary for digestion. Gallstones are a common cause of gallbladder pain.
Gas can accumulate in this area, causing pain and tenderness in the right side under the ribs, especially if you have digestive issues such as irritable bowel syndrome. Right-sided gas pain may also be confused with gallstones, Cooper notes.What organ is on right side under ribs? ›
Liver. Location: This large organ lies in the right upper abdomen, just below the rib cage. Various causes of pain affecting the liver include: Trauma in the form of blunt or sharp injury to the upper right abdominal wall.How can you tell the difference between gallbladder and liver pain? ›
In more severe cases, gallbladder pain may cause nausea, vomiting, fever, or jaundice. On the other hand, upper abdominal or liver pain may feel more like a dull ache or pressure in the right upper quadrant of the abdomen. It may also be accompanied by fatigue, weakness, or general discomfort.What can be mistaken for liver pain? ›
Liver pain can be dull and nonspecific, but it can also be severe. It may result in a backache. Liver pain is sometimes confused with a pain in the right shoulder, or in the abdomen, or the kidney.Can stress cause upper right quadrant pain? ›
Absolutely. Stress and anxiety are common causes of stomach pain and other GI symptoms.What does pain under right rib cage indicate? ›
Conditions that affect the gallbladder cause pain under the ribs on your right side because that is where the gallbladder is located. The gallbladder stores bile, which is necessary for digestion. Gallstones are a common cause of gallbladder pain.Is pancreatitis right upper quadrant pain? ›
The main symptom of pancreatitis is pain felt in the upper left side or middle of the abdomen. The pain: May be worse within minutes after eating or drinking at first, more commonly if foods have a high fat content. Becomes constant and more severe, lasting for several days.