From the Guidelines
The next step in evaluating right upper quadrant pain with a normal ultrasound typically involves further diagnostic testing based on clinical suspicion, with a CT scan with contrast often being recommended as it provides better visualization of the liver, gallbladder, pancreas, and surrounding structures that might be missed on ultrasound. This approach is supported by the American College of Radiology Appropriateness Criteria for right upper quadrant pain, which suggests that CT scans can help identify complications of cholecystitis, such as gangrene, gas formation, intraluminal hemorrhage, and perforation 1.
Diagnostic Considerations
When evaluating right upper quadrant pain with a normal ultrasound, it is essential to consider the following diagnostic steps:
- Laboratory tests, including liver function tests, amylase, lipase, and complete blood count, should be reviewed or repeated to assess for inflammatory or infectious processes 1.
- If biliary pathology is still suspected despite normal ultrasound findings, a HIDA scan may be appropriate to evaluate for functional gallbladder disorders or biliary dyskinesia 1.
- Depending on the patient's symptoms and risk factors, an upper endoscopy might be considered to evaluate for peptic ulcer disease, gastritis, or other upper gastrointestinal causes of pain.
- MRI with MRCP can also be useful in evaluating hepatic and biliary abnormalities that are not characterized by US, particularly in cases where other imaging tests are equivocal 1.
Clinical Approach
The approach to diagnosing right upper quadrant pain with a normal ultrasound should be tailored to the patient's specific presentation, taking into account the pattern, duration, and associated symptoms of the pain to guide the diagnostic pathway. If the pain persists without a clear diagnosis after these investigations, referral to a gastroenterologist or hepatologist for specialized evaluation may be necessary. According to the ACR Appropriateness Criteria, CT scans are preferred over MRI or US for evaluating suspected acute cholecystitis, especially in cases where complications are suspected 1.
Key Takeaways
- A normal ultrasound does not rule out biliary pathology, and further diagnostic testing is often necessary.
- CT scans with contrast are a useful next step in evaluating right upper quadrant pain with a normal ultrasound.
- Laboratory tests, HIDA scans, upper endoscopy, and MRI with MRCP may also be considered based on clinical suspicion and patient presentation.
- The diagnostic approach should be tailored to the patient's specific presentation and symptoms.
From the Research
Next Steps in Evaluating Right Upper Quadrant Pain
- If the ultrasound is normal, the next step is to consider other potential causes of right upper quadrant pain, as the differential diagnosis is broad and includes gastrointestinal and non-gastrointestinal causes 2.
- Hepatobiliary scintigraphy (HS) may be useful in defining the cause of right upper quadrant pain in patients with normal hepatobiliary ultrasound, as it can reveal a biliary cause in more than 70% of patients 3.
- A hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (HIDA-CCK) can be performed to assess the function of the gallbladder and biliary tree, and to diagnose biliary dyskinesia or other functional gallbladder disorders 4.
- It is also important to consider referred pain and broaden the differential diagnoses after several negative tests, as right upper quadrant pain can be caused by non-hepatobiliary conditions, such as a paraspinal abscess or discitis 5.
- Emergent right upper quadrant sonography can be used to evaluate patients with signs and symptoms suspicious for acute cholecystitis or diseases of the liver and biliary tree, and can help guide further evaluation and management 6.