Pain Under the Right Rib: Causes and Treatments

He pain below the right rib it is a very common reason for consultation both in emergency departments and in outpatient consultations; its intensity is very variable as well as its causes, which demands of the health professionals a lot of expertise in order to make a correct diagnosis.

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

The most important thing when evaluating a patient with pain below the right rib is a thorough interrogation, since this pain rarely occurs alone; On the contrary, it is accompanied by different associated symptoms that help to orient the diagnosis with enough precision.

Once the questioning 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 start the corresponding treatment.

Causes

Given that the right rib represents a kind of"anatomical intersection"near which are diverse structures of the abdomen, thorax and abdominal wall, it is necessary that the doctor pay attention to many details that allow him to identify with precision the cause of the pain.

In this sense, the main suspects to be taken into account (although they are not the only causes but the most frequent) 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 met, 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 extensive of all the causes and the complex of the differential diagnosis in some cases, in this post we will focus on the most frequent causes.

Pain urinating in the colon

It is known as colon to the thick portion of the intestine. It is an organ about three meters long that is located in the abdominal cavity forming a"C"that looks down.

This configuration makes it have two important bends, one below the right rib and another below the left.

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

In those cases in which the condition of the colon is generalized or when the segment involved is the liver angle of the organ (the one located below the right rib), it is common for the person to feel pain below the right rib.

In all these cases, the pain is colic and is associated with digestive symptoms such as abdominal distension, constipation or diarrhea.

Pain associated with gallbladder disease

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

In addition, the nerves that carry the painful sensation from both structures to the brain share a common path (metamera) making it very easy to confuse one with the other.

However, the clinical signs of gallbladder disease tend to guide the doctor with certainty, especially when it comes to persistent pain over time.

Usually the pain of the gallbladder is located below the right rib, is colic (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 fats, and there are usually no signs of compromise of the digestive tract as it does in the colon.

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

Pains originating in the anterior abdominal wall

The anterior abdominal wall is an intricate mesh of muscles, ligaments and nerves that take insertion in the ribs above, in the back column and the pelvic bone below.

The fibers of your 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, even though the muscles of the abdominal wall are so important, they usually have little resistance (unless it is a person in excellent physical condition), so any excessive work of the different muscle groups of The region may cause pain below the right rib.

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

Associated signs are rarely present except in cases of trauma to the abdominal wall, when bruising or area of ​​phlogosis may appear (reddening and local heat).

Pain due to 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"respirophasic"; that is, it increases with inspiration and decreases with expiration. In addition, respiratory symptoms such as cough or shortness of breath are associated and, generally, the abdomen does not present any finding that suggests disease in that area.

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

Treatment

The treatment of pain below the right rib is merely symptomatic and consists of non-steroidal anti-inflammatories just to alleviate the symptoms; however, they do not eliminate the cause.

In order to achieve a complete remission of symptoms it is essential that the physician identify the source of the problem and, based on this, the appropriate treatment is initiated; This treatment will depend on the cause. Grosso modo It can be said that the most common treatments are:

For pain originating in the colon

Medications designed to relieve abdominal distension, promote motility, facilitate intestinal transit, cure infections and, ultimately, restore normal functioning of the colon.

For pain associated with gallbladder disease

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

For pains originating in the anterior abdominal wall

Normally a short course of non-steroidal anti-inflammatory drugs, local cold and rest is sufficient to treat most cases. However, under specific conditions-such as bruises 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 thoracocentesis. Subsequently, treatment should be instituted to correct the cause of the pleural effusion, whenever possible.

References

1. Kingham, J. G., & Dawson, A.M. (1985). Origin of chronic right upper quadrant pain. Gut , 26 (8), 783-788.
2. Laing, F.C., Federle, M.P., Jeffrey, R.B., & Brown, T.W. (1981). Ultrasonic evaluation of patients with right upper quadrant pain. Radiology , 140 (2), 449-455.
3. Fernandez, J. N., Lopez, P. T., Montes, J. R., & Cara, M. L. (2009). Validity of tests performed to diagnose acute abdominal pain in patients admitted to an emergency department. Spanish Journal of Digestive Diseases , 2009 (101/9), 610-618.
4. Peter, N. G., Clark, L. R., & Jaeger, J. R. (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, E.T., Bat, L., Hegarty, J.E., Williams, C.B., & Dawson, A.M. (1980). Site of pain from the irritable bowel. The Lancet , 316 (8192), 443-446.
6. Westlake, P.J., Hershfield, N.B., Kelly, J.K., Kloiber, R., Lui, R., Sutherland, L.R., & Shaffer, E.A. (1990). Chronic right upper quadrant pain without gallstones: does HIDA scan predict outcome after cholecystectomy?. American Journal of Gastroenterology , 85 (8)
7. Shuman, W. P., Mack, L.A., Rudd, T.G., Rogers, J.V., & 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, E. M. W., & Venkatesh, S. K. (2009). Ascending retrocecal appendicitis presenting with right upper abdominal pain: utility of computed tomography. World Journal of Gastroenterology: WJG , fifteen (28), 3576.