From the Guidelines
For a 50-year-old patient with right upper quadrant pain and a history of gallbladder removal, I recommend starting with an abdominal ultrasound as the initial imaging study, followed by magnetic resonance cholangiopancreatography (MRCP) if the ultrasound is inconclusive. The ultrasound can evaluate for biliary duct dilation, stones in the common bile duct, and other potential causes of pain such as liver abnormalities, as suggested by the American College of Radiology Appropriateness Criteria for right upper quadrant pain 1.
Key Considerations
- Ultrasound is usually appropriate for the initial evaluation of right upper quadrant pain with suspected biliary disease, according to the ACR Appropriateness Criteria 1.
- MRCP provides detailed imaging of the biliary tree without radiation exposure and is particularly useful for detecting bile duct strictures, stones, or other post-cholecystectomy complications 1.
- If there is concern for acute pathology requiring immediate intervention, a contrast-enhanced CT scan of the abdomen and pelvis would be appropriate as it can quickly identify inflammation, infection, or obstruction.
Additional Imaging Modalities
- MRI with MRCP can be used to evaluate hepatic and biliary abnormalities that are not characterized by US, and it can perform superiorly to US in cases of gallstones in the gallbladder neck, the cystic duct, or the common bile duct 1.
- Noncontrast MRI with MRCP has excellent accuracy for visualization of normal and dilated bile ducts and detection of stone disease compared to noncontrast CT 1.
Laboratory Tests
- Laboratory tests, including liver function tests, amylase, and lipase, should accompany imaging to assess for conditions like post-cholecystectomy syndrome, choledocholithiasis, or sphincter of Oddi dysfunction.
Clinical Context
- Post-cholecystectomy pain can result from retained stones, biliary strictures, or other conditions that require specific visualization techniques for accurate diagnosis and appropriate management.
- The choice of imaging modality should be guided by the clinical presentation and the suspected underlying cause of the pain, as well as the availability and expertise of the imaging modalities.
From the Research
Imaging Modality for Right Upper Quadrant Pain
The recommended imaging modality for a 50-year-old patient with right upper quadrant pain and a history of cholecystectomy is ultrasound, as it is a fast, cost-effective, and dynamic modality that can provide a definitive diagnosis or a considerably narrowed list of differential possibilities 2, 3, 4.
Advantages of Ultrasound
- Allows for the differentiation of medical and surgical causes of upper abdominal pathology 2
- Can identify a variety of ultrasonographically diagnosable disease processes, including conditions of hepatic, pancreatic, adrenal, renal, gastrointestinal, vascular, and thoracic origin 4
- Is the primary imaging modality of choice for initial imaging assessment in patients with right upper quadrant pain 4
Alternative Imaging Modalities
- Magnetic resonance cholangiopancreatography (MRCP) may be considered in postcholecystectomy patients with a low to moderate probability of common bile duct stones, as it has a high accuracy in diagnosis and is less invasive than endoscopic retrograde cholangiopancreatography (ERCP) 5
- Computed tomography (CT) may be of use in the initial post-operative period or in cases where ultrasound is indeterminate 3, 6
Diagnostic Approach
- A right upper quadrant abdominal ultrasound, liver transaminases, alkaline phosphatase, and serum bilirubin are the tests most useful in differentiating biliary from non-biliary causes of the patient's symptoms 6
- Familiarity with the spectrum of disease processes outside of the gallbladder and biliary tree that may manifest with right upper quadrant pain is pivotal for early diagnosis and appropriate management 4