What is the workup for a patient presenting with pelvic pain, right upper quadrant (RUQ) abdominal pain, low-grade fever, and nausea?

From the Guidelines

For a patient presenting with pain in the pelvis and right upper quadrant (RUQ) accompanied by low-grade fever and nausea, a comprehensive workup should begin with a detailed history and physical examination, followed by initial laboratory tests including complete blood count, comprehensive metabolic panel, urinalysis, and blood cultures if fever is present. Imaging studies are essential, starting with an abdominal ultrasound to evaluate the gallbladder, liver, and biliary tract, as this constellation of symptoms raises concern for cholecystitis, cholelithiasis, or hepatobiliary issues, as discussed in the ACR Appropriateness Criteria for Right Upper Quadrant Pain 1. If ultrasound is inconclusive, a CT scan of the abdomen and pelvis with contrast would provide more detailed evaluation of potential causes including appendicitis, diverticulitis, pelvic inflammatory disease, or tubo-ovarian abscess, as recommended in the ACR Appropriateness Criteria for Acute Nonlocalized Abdominal Pain 1. For female patients of reproductive age, a pregnancy test is mandatory to rule out ectopic pregnancy. Additional tests may include lipase and amylase to assess for pancreatitis, and stool studies if there are accompanying gastrointestinal symptoms. If there is concern for gynecological pathology, a pelvic examination and transvaginal ultrasound may be warranted. This systematic approach helps identify the underlying cause, which could range from biliary disease to gynecological conditions, allowing for appropriate targeted treatment, and is supported by recent guidelines such as the 2022 update to the ACR Appropriateness Criteria for Right Lower Quadrant Pain 1. It's also important to consider the use of MRI as an alternative to CT, especially in cases where CT is inconclusive or not feasible, as discussed in the ACR Appropriateness Criteria for Acute Nonlocalized Abdominal Pain 1. The management of intra-abdominal infections, as outlined in the WSES 2016 consensus conference, also emphasizes the importance of a step-up approach for diagnosis, tailored to the clinical setting and patient's age, beginning with clinical and laboratory examination and progressing to imaging examinations 1. Overall, the key to managing a patient with pelvic pain, RUQ abdominal pain, low-grade fever, and nausea is to follow a systematic and evidence-based approach to identify the underlying cause and provide targeted treatment.

From the Research

Workup for Pelvic Pain, Right Upper Quadrant (RUQ) Abdominal Pain, Low-Grade Fever, and Nausea

The workup for a patient presenting with pelvic pain, RUQ abdominal pain, low-grade fever, and nausea involves a combination of clinical evaluation, laboratory tests, and imaging studies.

• The initial evaluation should include a thorough medical history and physical examination to identify potential causes of the symptoms.
• Laboratory tests such as complete blood count (CBC), blood chemistry tests, and liver function tests may be ordered to help identify the underlying cause of the symptoms.
• Imaging studies are crucial in the workup of RUQ abdominal pain, with ultrasonography (US) being the primary imaging modality of choice for initial imaging assessment 2, 3.
• US is a fast, cost-effective, and dynamic modality that can provide a definitive diagnosis or a considerably narrowed list of differential possibilities, including conditions of hepatic, pancreatic, adrenal, renal, gastrointestinal, vascular, and thoracic origin 2.
• In some cases, subsequent computed tomography (CT), magnetic resonance (MR) imaging, MR cholangiopancreatography, or cholescintigraphy may be considered, depending on the clinical situation and US findings 2, 4.
• The choice of imaging modality may depend on the specific clinical presentation and the suspected underlying cause of the symptoms, with CT being noninferior to US in both ruling in and ruling out the diagnosis of cholecystitis in adult patients undergoing emergency evaluation of RUQ pain 4.
• A low ejection fraction on cholescintigraphy does not predict clinical outcome or histologic features of chronic cholecystitis without gallstones 5.
• In some cases, genetic testing may be necessary to diagnose conditions such as low phospholipid-associated cholelithiasis (LPAC) syndrome, which can cause RUQ abdominal pain and fever 6.

Differential Diagnoses

The differential diagnoses for a patient presenting with pelvic pain, RUQ abdominal pain, low-grade fever, and nausea include:

• Acute cholecystitis
• Cholelithiasis
• Chronic cholecystitis
• Low phospholipid-associated cholelithiasis (LPAC) syndrome
• Hepatic, pancreatic, adrenal, renal, gastrointestinal, vascular, and thoracic conditions
• Pelvic inflammatory disease
• Other causes of pelvic pain and RUQ abdominal pain.

Imaging Modalities

The imaging modalities used in the workup of RUQ abdominal pain include:

• Ultrasonography (US)
• Computed tomography (CT)
• Magnetic resonance (MR) imaging
• MR cholangiopancreatography
• Cholescintigraphy
• Other imaging modalities as needed to evaluate the specific clinical presentation and suspected underlying cause of the symptoms 2, 4, 3.