From the Guidelines
The workup for right upper quadrant pain with CT findings of hepatomegaly and fatty liver should prioritize a comprehensive assessment of liver function and potential causes of liver disease, as outlined in the 2021 guidelines for hepatobiliary cancers 1. The initial steps in the workup should include:
- Comprehensive blood tests: liver function tests (ALT, AST, alkaline phosphatase, bilirubin), complete blood count, lipid panel, fasting glucose, and HbA1c
- Hepatitis serology, iron studies, and autoimmune markers to exclude alternative diagnoses
- Assessment of liver reserve and comorbidity, as well as staging, which may involve a multidisciplinary evaluation 1
- Consideration of referral to a hepatologist for further evaluation and management
Additional testing may include:
- Ultrasound elastography or FibroScan to assess liver stiffness and fibrosis
- Chest CT and bone scan if clinically indicated
- Abdominal/pelvic CT or MRI with contrast if not previously done or needs updating 1
Management primarily involves lifestyle modifications, including:
- Gradual weight loss of 7-10% through a Mediterranean or low-carbohydrate diet
- Regular exercise (150 minutes weekly of moderate activity)
- Tight control of associated conditions like diabetes and hyperlipidemia For patients with non-alcoholic steatohepatitis (NASH) or significant fibrosis, referral to a hepatologist is warranted for consideration of medications such as vitamin E (800 IU daily) in non-diabetic patients or pioglitazone in diabetic patients 1.
It is also important to note that the 2019 ACR Appropriateness Criteria for right upper quadrant pain recommend US abdomen as the initial evaluation for suspected biliary disease 1, and MRI with IV contrast may be useful in evaluating the hepatobiliary system, especially in cases of suspected acute cholecystitis 1. However, the most recent and highest quality study, the 2021 guidelines for hepatobiliary cancers, should be prioritized in guiding the workup and management of right upper quadrant pain with CT findings of hepatomegaly and fatty liver 1.
From the Research
Workup for Right Upper Quadrant Pain
The workup for right upper quadrant pain involves a combination of clinical evaluation, laboratory tests, and imaging studies.
- For patients presenting with right upper quadrant pain, a computed tomography (CT) scan showing hepatomegaly and fatty liver disease may indicate a liver-related condition 2.
- The initial workup for suspected liver disease includes viral hepatitis serologies, ferritin, transferrin saturation, and abdominal ultrasonography, as well as complete blood count, liver function tests, and prothrombin time/international normalized ratio 2.
- CT and MR are appropriate first-line imaging techniques for patients without fever or a positive Murphy sign 3.
- Ultrasound is the primary imaging modality for assessing acute right upper quadrant pain, but CT is valuable for confirming the extent and nature of complications 4.
- In cases where ultrasound and CT are both performed, CT may show acute nongallbladder abnormalities that were missed on ultrasound 5.
Additional Considerations
- The differential diagnosis for right upper quadrant pain should be broadened if initial tests are negative, and referred pain should be considered 6.
- Noninvasive tests, such as the aspartate transaminase to platelet ratio index score and Fibrosis 4 score, can be useful in assessing liver fibrosis 2.
- Management of chronic liver disease includes directed counseling, laboratory testing, and ultrasound monitoring, with treatment goals focused on preventing cirrhosis, decompensation, and death 2.