From the Guidelines
The patient's presentation of right upper quadrant pain radiating to the shoulders, with a significantly elevated white blood cell count but normal liver and pancreatic function tests, most likely suggests acute cholecystitis, and I would recommend starting with an abdominal ultrasound to evaluate the gallbladder, liver, and biliary tree, as it is the first choice of investigation for biliary symptoms or right upper quadrant abdominal pain 1. The most common causes of this presentation include:
- Acute cholecystitis
- Biliary colic
- Choledocholithiasis
- Cholangitis
- Peptic ulcer disease
- Pneumonia with pleural irritation
- Subdiaphragmatic abscess To establish an accurate diagnosis, the following steps should be taken:
- Abdominal ultrasound to evaluate the gallbladder, liver, and biliary tree, which can identify gallstones, gallbladder wall thickening, or biliary dilation 1
- Chest X-ray to rule out lower lobe pneumonia or pleural effusion
- If initial tests are inconclusive, a CT scan of the abdomen with contrast to provide more detailed imaging of all abdominal organs and potential inflammatory processes 1
- Additional blood tests, including C-reactive protein and erythrocyte sedimentation rate to assess inflammation, blood cultures if infection is suspected, and a complete metabolic panel
- If upper GI symptoms are prominent, an upper endoscopy might be warranted to evaluate for peptic ulcer disease The markedly elevated white count strongly suggests an infectious or inflammatory process, and despite normal liver function tests, biliary pathology remains possible as early cholecystitis can present before laboratory abnormalities develop 1. The radiation of pain to both shoulders (referred pain) is consistent with diaphragmatic irritation, which can occur with gallbladder disease or subdiaphragmatic processes. Prompt diagnosis is essential as the elevated white count indicates a significant inflammatory response requiring timely intervention.
From the Research
Common Causes of Right Upper Quadrant Abdominal Pain
The common causes of right upper quadrant abdominal pain radiating to the back and shoulders with elevated white blood cell (WBC) count, normal liver function tests, and normal pancreatic enzymes can be attributed to several factors, including:
- Gallbladder pathologies, such as acute or chronic cholecystitis, adenomyomatosis, cancer, polyps, and postoperative complications 2
- Biliary tract disease, which can be assessed using contrast-enhanced ultrasonography (CEUS) to differentiate between tumorous lesions and non-tumorous lesions 3
- Anomalous position of the gallbladder, which can be detected using ultrasound (US) and may present with varying symptoms and findings 4
Diagnostic Tools
In terms of diagnostic tools, the following can be used to evaluate right upper quadrant abdominal pain:
- Ultrasound (US) as the initial evaluation modality of choice for patients presenting with right upper quadrant pain 2
- Contrast-enhanced ultrasound (CEUS) for the assessment of gallbladder disease and biliary tract disease 3, 5
- Computed Tomography (CT) abdomen as a useful imaging modality for diagnosing acute appendicitis, although it may not be directly relevant to gallbladder disease 6
Laboratory Markers
Elevated WBC count can be an indicator of inflammation or infection, but it may not be a specific marker for gallbladder disease or biliary tract disease. C-reactive protein (CRP) level may be a more indicative marker for acute appendicitis, but its relevance to gallbladder disease is not well-established 6