From the Guidelines
The initial workup for a patient with right upper quadrant (RUQ) pain in urgent care should include a thorough history, physical examination, and targeted laboratory tests, with ultrasound (US) of the abdomen as the first choice of investigation for biliary symptoms or right upper quadrant abdominal pain, as recommended by the American College of Radiology 1. Begin by assessing vital signs and performing a focused abdominal exam, noting tenderness, guarding, or Murphy's sign. Order laboratory tests including:
- Complete blood count
- Liver function tests (ALT, AST, alkaline phosphatase, bilirubin)
- Lipase
- Urinalysis Point-of-care ultrasound, if available, can help identify gallstones, biliary dilation, or other pathology. Management depends on the suspected diagnosis but typically includes pain control with:
- Acetaminophen 650-1000mg every 6 hours
- NSAIDs like ibuprofen 400-600mg every 6 hours if not contraindicated For suspected biliary colic or cholecystitis without complications, patients can be discharged with pain medication, antiemetics like ondansetron 4mg every 8 hours as needed, and clear instructions to follow a low-fat diet and seek immediate care if symptoms worsen. Patients should follow up with primary care or gastroenterology within 1-2 days. For concerning findings such as fever, significant laboratory abnormalities, intractable pain, or inability to tolerate oral intake, arrange transfer to an emergency department for advanced imaging (CT scan or formal ultrasound), IV antibiotics if infection is suspected, and possible surgical consultation, as suggested by the Infectious Diseases Society of America 1. This approach balances thorough evaluation with appropriate resource utilization in the urgent care setting.
From the Research
Initial Workup for RUQ Abdominal Pain
The initial workup for a patient presenting with right upper quadrant (RUQ) abdominal pain in an urgent care setting involves a combination of history, physical examination, laboratory testing, and diagnostic imaging 2.
- History: A thorough history is essential to identify potential causes of RUQ pain, including gastrointestinal and non-gastrointestinal causes.
- Physical examination: A physical examination should be performed to assess for tenderness, guarding, and other signs of peritonitis.
- Laboratory testing: Recommended tests may include a complete blood count, C-reactive protein, hepatobiliary markers, electrolytes, creatinine, glucose, urinalysis, lipase, and pregnancy testing 3.
- Diagnostic imaging: Ultrasonography is the study of choice for right upper quadrant pain, and can aid in the diagnosis of conditions such as cholelithiasis, urolithiasis, and appendicitis 3.
Management of RUQ Abdominal Pain
The management of RUQ abdominal pain depends on the underlying cause. For example, acute cholecystitis is generally treated with early laparoscopic cholecystectomy (ELC) within 72 hours of diagnosis, and medical management comprising fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics 4.
- Medical management: Patients with acute cholecystitis may require medical management before undergoing ELC, including fasting, intravenous fluid infusion, antimicrobial therapy, and analgesics.
- Surgical management: ELC is the best treatment for acute cholecystitis, and should be performed within 72 hours of diagnosis.
- Special considerations: Certain populations, such as pregnant women, cirrhotic patients, and elderly patients, may require a different approach to management 4.
Potential Causes of RUQ Abdominal Pain
There are several potential causes of RUQ abdominal pain, including:
- Cholelithiasis: Gallstones can cause RUQ pain, and may be diagnosed using ultrasonography 3.
- Acute cholecystitis: Inflammation of the gallbladder can cause RUQ pain, and is generally treated with ELC 4.
- Biliary sludge: Ceftriaxone, a commonly used antibiotic, can cause biliary sludge and pseudolithiasis, leading to RUQ pain 5, 6.