The differential diagnosis of biliary colic includes other conditions associated with upper abdominal pain, including gastritis, gastroesophagal reflux, pancreatitis, hepatitis, and peptic ulcer disease. Atypical myocardial infarction should be considered in older patients. Acute renal colic can be associated with upper abdominal and upper back pain. Both conditions can also be associated with flank tenderness, nausea, and vomiting. Renal colic does not have a circadian rhythm, and the pain is colicky, not continuous, as in biliary colic. Nonetheless, it can be difficult to distinguish biliary from renal colic, and definitive imaging studies may be needed to make the correct diagnosis. Acute pyelonephritis, like cholecystitis, can be associated with flank and upper quadrant pain, but pyuria confirms the former diagnosis. Appendicitis can sometimes be associated with RUQ pain, especially in pregnancy or in patients with a retrocecal or redundant appendix. In women of childbearing age, the differential diagnosis is expanded to include a wide variety of gynecologic disorders, including pelvic inflammatory disease, perihepatitis (Fitzhugh-Curtis syndrome), and ectopic pregnancy. Pregnancy testing, gynecologic history, and pelvic examination should focus on the correct diagnosis. Finally, pneumonia or pleural effusion can be associated with RUQ pain. Diagnosis is confirmed by chest x-ray. However, pancreatitis can also be associated with pleural effusions, usually on the right.
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