This leaflet looks at pains which can develop in the upper part of the tummy (abdomen) on your right-hand side. It deals with possible causes, how a diagnosis might be made and what the treatment might be.
Where is my right upper quadrant?
The right upper quadrant (RUQ) is a section of your tummy (abdomen). Look down at your tummy, and mentally divide the area from the bottom of your ribs down to your pubes into four quarters. The quarter on your right side closest to your ribs is your RUQ.
By Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.
What is in my right upper quadrant?
By Mariana Ruiz Villarreal, modified by Madhero88 [Public domain], via Wikimedia Commons
The organs within your RUQ are your:
- Part of the pancreas.
- Duodenum and some other parts of your large and small bowel.
- Right kidney (at the back behind the other organs).
There are also the skin and nerves of that section.
What might give me pain there?
Pain can come from any of the organs mentioned above, and these are the source for the most common causes. But the human body is never simple, so pain can also come from other areas of your body. This is called 'referred' pain. So this widens the possible options.
In adults, gallstones are one of the most frequent causes of pain in this area. Other common possibilities are kidney infections, shingles and ulcers in the upper part of the guts. Less common causes are discussed later in this leaflet.
What are the most common causes of right upper quadrant pain?
Gallstones and gallbladder problems
Gallstones don't necessarily cause any symptoms but when they get stuck they can give you pain. This is called biliary colic and is typically a severe crampy pain in the RUQ shortly after eating a fatty meal. An infection may ensue, called cholecystitis, which will give you a more persistent pain in the RUQ, with a high temperature.
Kidney stones and infections
Problems with the kidney tend to give you pain more around the right-hand side of the RUQ, or in your back (loin), but the pain may spread and involve the front of the tummy (abdominal) area. Kidney stones can cause a severe pain (usually round the back) which occurs in spasms lasting from a few minutes to several hours. There may also be blood in your wee. A kidney infection can cause pain anywhere along your urinary tract. So this could be anywhere from the loin in your back, around to the front, the RUQ, or down to the lower part of your tummy. It may be associated with a fever, pain when you wee, or going to the loo more frequently.
In some cases you can get the pain from shingles before the rash appears. You may have pain for a few days before a blistery rash appears. The pain tends to be quite sharp or burning, and you may feel not quite right in yourself. The RUQ is a common place for a shingles rash.
Other people find they continue to get a pain long after the rash of shingles has gone. This is called postherpetic neuralgia.
The liver takes up a large part of your RUQ but, in fact, it doesn't very often give you pain. Causes of pain from the liver include:
- Infection causing inflammation of the liver (hepatitis). This will usually result in jaundice and a fever and feeling generally unwell in addition to some pain in that area. Pain is not necessarily a feature. There are a number of types of hepatitis, including hepatitis A, hepatitis B and hepatitis C.
- Abscess. This is a collection of pus around the liver or under the ribs, causing pain, tenderness and fever.
- Alcoholic liver disease. Too much alcohol can damage your liver, which may affect its function, turn your skin yellow and give you RUQ pain.
- Liver cancer - this can start in the liver or have spread from other cancers. Primary cancer in the liver is unusual. The liver may enlarge in certain blood cancers, such as lymphomas or leukaemias, causing discomfort.
Several problems with your guts can give you pain in the RUQ. For example:
- Duodenal ulcer. Pain typically comes on a couple of hours after eating and may be improved by taking antacids. The level of pain can gradually build up over time, eventually becoming severe and may be associated with bringing up (vomiting) blood. This is an emergency and you should call an ambulance to go directly to hospital if this occurs. See separate leaflet called Duodenal Ulcer for more information.
- Gastroenteritis. Infections of your guts tend to give you pain all over your tummy, or more in the middle; however, occasionally the pain may be in the RUQ area. It is usually associated with diarrhoea and/or being sick (vomiting). You may have a mild fever. See separate leaflet called Gastroenteritis for more information.
- Indigestion (dyspepsia) can give you a pain in the upper part of your tummy, along with bloating and acid reflux. See separate leaflet called Indigestion (Dyspepsia) for more information.
- Longer-term conditions such as Crohn's disease and ulcerative colitis can give rise to pain anywhere in the tummy at times. They usually cause loose stools, sometimes with blood. See separate leaflets called Crohn's Disease and Ulcerative Colitis for more information.
- The RUQ is not a common place for pain in irritable bowel syndrome, but in some people it may occur. Pain is usually on and off and accompanied by bloating and diarrhoea and/or constipation. See separate leaflet called Irritable Bowel Syndrome for more information.
What are the most common causes of right upper quadrant pain in pregnancy?
Any of the above conditions can cause pain in the RUQ whether you are pregnant or not, so you should always be checked out. However, in pregnancy a common cause of discomfort is the sheer pressure of the womb pressing on other organs, and pressing them into the diaphragm. Also, problems with indigestion tend to be common in pregnancy, again at least partly due to the pressure on the stomach. Urinary tract infections are also more common in pregnancy.
What are the most common causes of right upper quadrant pain in children?
In young children it is often quite difficult for them to show exactly where the pain is. If this is the case, the range of options widens to almost any cause of tummy ache. In children common causes include:
- Mesenteric adenitis. In children with infections such as colds, glands within the tummy commonly become inflamed giving them tummy ache.
- Appendicitis. Usually this gives pain in the lower right part of the tummy. However, often the pain of appendicitis starts in the middle of the tummy, around the tummy button. And if a child can't show you exactly where the pain is, or if the appendix has burst (ruptured), appendicitis may be a possible diagnosis to consider.
- Pneumonia. Infections of the lower parts of the lungs may cause pain in the tummy area.
What are the other possible causes?
As well as the more common causes already described, there are many other conditions which occasionally cause RUQ pain.
- Heart attack (myocardial infarction). Heart attacks normally present with chest pain, radiating to the left arm, or a tightness in the chest. Occasionally they can cause pain in the RUQ. Usually you would feel unwell in yourself if you were having a heart attack - for example, feel sweaty or breathless.
- Pneumonia. This is an infection in the lung and normally gives you cough, and a high temperature (fever), with or without breathlessness and pain in your chest. However, if the infection is in the lower part of your right lung, you may feel the pain in your RUQ. Other types of chest infections such as pleurisy can also sometimes give you a pain so low in your chest that it feels as if it is in your tummy (abdomen).
- Problems with the pancreas. This includes pancreatitis and cancer of the pancreas. Usually problems with the pancreas give you pain more in the middle of your upper tummy, which radiates to your back between your shoulder blades. But occasionally it can cause a pain on the right side.
- A serious complication of type 1 diabetes, called diabetic ketoacidosis. This makes you very unwell generally, but occasionally tummy pain can be one of the symptoms.
- In a condition called Addison's disease, a complication called an Addisonian crisis occasionally can give you tummy pain. Again you would be unwell in other ways other than the pain.
- Rare complications of pregnancy affecting the liver.
- Pain radiating from problems with the spine. If nerves are being irritated or squashed, pain in any of the areas that nerve supplies can occur. Sometimes spinal problems cause pains in the tummy area.
- Pain which is referred from problems in the pelvis, which is below the tummy. This might include conditions such as infections (pelvic inflammatory disease) or ovarian cysts. Again the pain in the RUQ would usually be accompanied by one or more typical symptoms of these conditions.
- Budd-Chiari syndrome is a rare condition where the veins in the liver become blocked.
These listed causes are not exhaustive, and many other conditions occasionally cause pain in the RUQ.
Should I see a doctor?
Yes, if you have a pain which doesn't settle, you will probably need to see a health professional to help work out the cause. See a doctor urgently if:
- Your skin has turned yellow (this is called jaundice).
- Your wee has gone darker and your poo lighter (this suggests a blockage in the tubes around your liver and gallbladder).
- Your pain is very severe.
- You have recently lost weight without trying.
- You are bringing up (vomiting) blood, or have blood in your poo (including a very dark coloured poo which can be caused by old blood from high up in the gut).
- You have a high temperature with shaking (rigors).
- You feel out of breath.
How will they find the cause of the pain?
The doctor will be able to get a reasonable idea of the reason for the pain by asking you some questions and examining you. They may want to test a sample of your urine. You may then have to have further tests, depending on their suspicions at this stage. These may be done urgently or in due course, again depending on their suspicions and how much pain you are in. Possible tests might include blood tests, an ultrasound scan, a look into your stomach and upper bowel with a camera (endoscopy) and other scans and 'scopes'.
What are the usual tests?
Your doctor will narrow the (enormous) field of possible diagnoses by talking to you and by examining you. They may be able to find the cause simply from doing so. For example, if they find the typical rash of shingles, you will need no further tests to find the cause. If they find a liver enlargement (unusual) this suggests the problem is in the liver. If examination is normal, that already rules out quite a few possible diagnoses. The doctor will certainly need to feel your tummy (abdomen) in the area you have the pain, but may also need to examine other parts too, such as the rest of your tummy and your chest.
You will probably be asked to provide a sample of urine, to check the colour and to rule out kidney problems.
An ultrasound scan is often a good next test. It is simple to perform and can look for common conditions such as gallstones. It can also give an idea about any liver abnormality or enlargement and can rule out some kidney and pancreas problems.
What other tests might be needed?
This depends on what has been discovered so far through the tests above. More specific tests may be needed depending on where it is thought the pain is coming from. If your pain is thought to be coming from your guts, you are likely to have some type of endoscopy, which is an examination of the inside of your guts with a camera. A more specific type called endoscopic retrograde cholangiopancreatography (ERCP) can examine the tubes around your gallbladder and pancreas. In some cases special radio-isotope scans may be used. These show up certain organs and tissues by using a small dose of a radioactive chemical.
If you might have a kidney problem, you might have a specialised form of computerised tomography (CT) scan, with a dye injected to highlight your urinary tract.
A chest X-ray might be needed to rule out a problem in your lungs, such as infection. If the pain is thought to come from the nerves around your spine, a magnetic resonance imaging (MRI) scan may be helpful. An MRI of the affected area of your tummy may also be useful in some cases.
Nobody will need ALL these tests. You are likely to need a few tests only. For example, if gallstones are found on the ultrasound scan in the first place, you would need no other tests.
What if no cause is found after tests?
Obviously if any serious cause has been ruled out, this is a relief, but doesn't settle the pain. There are so many possible causes that multiple tests may be needed for your doctor to be sure that they have ruled out all serious causes.
In some cases when tests are normal, a condition called sphincter of Oddi dysfunction may be diagnosed. The sphincter of Oddi is a tight muscle band which controls the flow of a substance called bile which helps your digestion. It is located in one of the tubes around your liver and gallbladder. Even after having the gallbladder removed (a cholecystectomy), some people continue to get a pain which feels much like gallstone pain. There may not be anything to find on scans, etc, and sometimes this pain is put down to sphincter of Oddi problems.
What treatment will I need?
There is no single answer to this until you know what the cause of your pain is. See the relevant leaflet for the condition you are diagnosed with. Treatments for a few of the common causes of RUQ pain are briefly discussed below.
- Gallstones. In some cases symptoms are not very troublesome and can be managed by sticking to a low-fat diet only. Many people choose to have their gallbladder removed, in an operation called a cholecystectomy. This can usually be done by keyhole (laparoscopic) surgery.
- Cholecystitis is treated initially with antibiotics, usually in hospital via injections or a drip (intravenous antibiotics). Once the infection has been treated, a cholecystectomy is usually advised.
- Shingles. The pain and rash settle on their own in time, but some people may be advised to take an antiviral tablet to help speed this process up.
- Kidney infections are treated with antibiotics. Mild infections can be treated with antibiotics at home. If you are very unwell you may need admission to hospital for intravenous antibiotics and fluids.
- Kidney stones. Small kidney stones pass on their own eventually, in which case you will need to drink plenty of fluids and take strong painkillers. Larger kidney stones may need one of a number of procedures done to break them up or remove them altogether.
- A duodenal ulcer is usually treated with acid-suppressing medication, as is indigestion.
What is the outlook?
Again, outlook (prognosis) depends entirely on the cause of the pain. Some conditions settle very quickly on their own (for example, gastroenteritis) or with the help of antibiotics (for example, a kidney infection). Others, such as gallstones, can be cured with treatment. Some, such as postherpetic neuralgia and sphincter of Oddi problems, rumble on for a long time. Your doctor should be able to give you an idea of the outlook once a diagnosis has become clear.
Further reading and references
Kim JS; Acute Abdominal Pain in Children. Pediatr Gastroenterol Hepatol Nutr. 2013 Dec16(4):219-224. Epub 2013 Dec 31.
Wilcox CM; Sphincter of Oddi dysfunction Type III: New studies suggest new approaches are needed. World J Gastroenterol. 2015 May 2121(19):5755-61. doi: 10.3748/wjg.v21.i19.5755.
Cholecystitis - acute; NICE CKS, January 2017 (UK access only)
Gallstones; NICE CKS, February 2015 (UK access only)
Ahmed F, Fogel EL; Right upper quadrant pain and a normal abdominal ultrasound. Clin Gastroenterol Hepatol. 2008 Nov6(11):1198-201. doi: 10.1016/j.cgh.2008.06.020.
Cartwright SL, Knudson MP; Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician. 2015 Apr 191(7):452-9.
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