A 45-year-old overweight woman has recurrent bouts of severe right upper quadrant and epigastric pain, lasting a few hours and often after fatty meals, radiating to the tip of the right scapula, with no fever and normal liver tests. What is the most likely diagnosis?

Answer: E. Biliary colic

Biliary colic

Severe, self-limiting RUQ/epigastric pain after fatty meals, radiating to the inferior angle/tip of the right scapula, with no fever and normal LFTs, is biliary colic.

Mechanism

• A stone transiently impacts in Hartmann's pouch / the neck of the gallbladder (or the distal CBD/ampulla); the gallbladder contracts against the obstruction, then the stone falls back and the pain resolves.

Why the pain refers to the scapula

• The visceral nerve supply of the gallbladder is T7-T9, so pain refers to the corresponding somatic dermatomes (interscapular region/inferior angle of the scapula).

The 'classic' patient and diagnosis

• Often 'fat, fertile, female, forty, flatulent'; diagnosis is clinical plus ultrasound.
• Treatment of an attack: analgesia and rest; definitive treatment is cholecystectomy.