PAIN UNDER THE RIGHT RIB: CAUSES AND TREATMENTS - MEDICINE - 2024

The pain under the right rib is a common reason for consultation both in emergency departments and outpatient clinics; Its intensity is highly variable as well as its causes, which requires a lot of skill from healthcare professionals in order to make a correct diagnosis.

When pain under the rib is mild and temporary, most of the time patients resolve it on their own with the administration of anti-inflammatories. However, when the intensity of the pain exceeds the tolerance of the patient, if the symptom does not improve or is prolonged over time, they decide to seek medical advice.

The most important thing when evaluating a patient with pain under the right rib is a thorough history, as this pain rarely occurs alone; on the contrary, it is accompanied by different associated symptoms that help to guide the diagnosis with enough precision.

Once the interrogation sheds light on the possible causes, a thorough physical examination should be carried out to identify the clinical signs that confirm the diagnosis, in order to initiate the corresponding treatment.

Causes

Since the right rib represents a kind of "anatomical intersection" near which various structures of the abdomen, thorax, and abdominal wall meet, the physician needs to pay attention to many details that allow him to accurately identify the cause of the disease. pain.

In this sense, the main suspects to take into account (although they are not the only causes but the most frequent ones) are:

- Pain originating in the colon.

- Pain associated with gallbladder disease.

- Pains originating in the anterior abdominal wall.

- Pain product of pleuropulmonary affections that involve the right lung.

Once the most common diagnoses have been excluded, if the cause has not yet been found, it is pertinent to carry out complementary studies to rule out less common but generally more serious pathologies, such as:

- Perforated peptic ulcer.

- Intra-abdominal tumors.

- Serositis (associated with autoimmune diseases such as lupus, among others).

- Ascites (accumulation of fluid in the abdominal cavity).

- Appendicitis (in cases of long, ascending retrocecal appendix).

Due to the length of all causes and the complexity of the differential diagnosis in some cases, in this post we will focus on the most frequent causes.

Urinary pain in the colon

The large portion of the intestine is known as the colon. It is an organ about three meters long that is located in the abdominal cavity forming a "C" that faces downward.

This configuration results in two major kinks, one below the right rib and one below the left.

When there is a condition that causes inflammation, distention, or decreased motility of the colon, pain usually occurs. This pain varies in location depending on the area of ​​the colon affected.

In those cases in which the affection of the colon is generalized or when the involved segment is the hepatic flexure of the organ (the one that is located below the right rib), it is common for the person to feel pain under the right rib.

In all these cases, the pain is colicky and is associated with digestive symptoms such as bloating, constipation or diarrhea.

Pain associated with gallbladder disease

Anatomically, the gallbladder rests practically on the upper edge of the hepatic flexure of the colon, so it is sometimes difficult to know if the problem is in one or the other organ due to its proximity.

In addition, the nerves that carry pain sensation from both structures to the brain share a common pathway (metamera) making it very easy to mistake one for the other.

However, the clinical signs of gallbladder disease usually guide the doctor with considerable certainty, especially when it comes to pain that persists over time.

Gallbladder pain is usually located below the right rib, is colicky (intermittent) and radiates to the right shoulder, something that does not happen with the colon.

In addition, there is a clear association with the consumption of certain foods, particularly those rich in fat, and there are usually no signs of compromise of the digestive tract as there is in the colon.

Ultimately, whenever there is suspicion that pain under the right rib has its origin in diseases of the gallbladder (the most common being gallstones or "stones" in the gallbladder), abdominal ultrasound is helpful in establish the definitive diagnosis.

Pain originating in the anterior abdominal wall

The anterior abdominal wall is an intricate meshwork of muscles, ligaments, and nerves that insert into the ribs above, the spine behind, and the pelvic bone below.

The fibers of its muscles are oriented in multiple directions, so that they not only keep the abdominal contents "inside" the abdomen, but also give the trunk the capacity of a wide range of movements.

However, although the abdominal wall muscles are so important, they generally have little resistance (unless you are in excellent physical condition), so any excessive work of the different muscle groups of the region can cause pain under the right rib.

In these cases the pain is usually continuous, associated with a well-characterized physical event (exercise, work, etc.) and of sudden onset.

Associated signs are seldom present except in cases of trauma to the abdominal wall, when hematomas or an area of ​​phlogosis (redness and local heat) may appear.

Pain resulting from pleuropulmonary conditions involving the right lung

Diseases that affect the base of the right lung and the pleura in that area of ​​the chest can cause pain below the right rib.

In these cases the pain is "respirofásico"; that is, it increases with inspiration and decreases with expiration. In addition, respiratory symptoms such as cough or shortness of breath are associated, and the abdomen generally does not present any findings suggesting disease in that area.

The pleuropulmonary diseases most frequently associated with pain below the right rib are right basal pneumonia, right pleural effusion (although this does not always present with pain), and lung abscesses involving the lower segments of the right lung.

Treatment

Treatment of pain under the right rib is merely symptomatic and consists of non-steroidal anti-inflammatory drugs only to relieve symptoms; however, they do not eliminate the cause.

In order to achieve a complete remission of the symptoms, it is essential that the doctor identify the origin of the problem and, based on this, initiate the appropriate treatment; this treatment will depend on the cause. Roughly it can be said that the most common treatments are:

For pain originating in the colon

Medications intended to relieve abdominal distention, promote motility, facilitate intestinal transit, cure infections, and ultimately restore normal colon function.

For pain associated with gallbladder disease

In these cases, the definitive treatment is surgery to remove the gallbladder.

For pain originating in the anterior abdominal wall

Usually a short course of non-steroidal anti-inflammatory drugs, local cold, and rest is sufficient to treat most cases.

However, in specific conditions - such as bruising or extensive tears of the muscles of the abdominal wall - some type of surgical intervention may be necessary.

For pain resulting from pleuropulmonary conditions involving the right lung

Antibiotics are administered in cases of infections and abscesses, while in patients with pleural effusion it must be drained by thoracentesis.

Subsequently, treatment should be established to correct the cause of the pleural effusion, whenever possible.

References

1. Kingham, JG, & Dawson, AM (1985). Origin of chronic right upper quadrant pain. Gut, 26 (8), 783-788.
2. Laing, FC, Federle, MP, Jeffrey, RB, & Brown, TW (1981). Ultrasonic evaluation of patients with acute right upper quadrant pain. Radiology, 140 (2), 449-455.
3. Fernández, JN, López, PT, Montes, JR, & Cara, ML (2009). Validity of tests performed to diagnose acute abdominal pain in patients admitted at an emergency department. Spanish Journal of Digestive Diseases, 2009 (101/9), 610-618.
4. Peter, NG, Clark, LR, & Jaeger, JR (2004). Fitz-Hugh-Curtis syndrome: a diagnosis to consider in women with right upper quadrant pain. Cleveland Clinic journal of medicine, 71 (3), 233-241.
5. Swarbrick, ET, Bat, L., Hegarty, JE, Williams, CB, & Dawson, AM (1980). Site of pain from the irritable bowel. The Lancet, 316 (8192), 443-446.
6. Westlake, PJ, Hershfield, NB, Kelly, JK, Kloiber, R., Lui, R., Sutherland, LR, & Shaffer, EA (1990). Chronic right upper quadrant pain without gallstones: does HIDA scan predict outcome after cholecystectomy ?. American Journal of Gastroenterology, 85 (8).
7. Shuman, WP, Mack, LA, Rudd, TG, Rogers, JV, & Gibbs, P. (1982). Evaluation of acute right upper quadrant pain: sonography and 99mTc-PIPIDA cholescintigraphy. American Journal of Roentgenology, 139 (1), 61-64.
8. Ong, EMW, & Venkatesh, SK (2009). Ascending retrocecal appendicitis presenting with right upper abdominal pain: utility of computed tomography. World Journal of Gastroenterology: WJG, 15 (28), 3576.