What should I do for upper quadrant pain and vomiting that has lasted for 4 days?

Immediate Evaluation and Management for 4-Day Upper Quadrant Pain with Vomiting

You need urgent abdominal ultrasound today to evaluate for acute cholecystitis, which is life-threatening if left untreated beyond 4 days, and if positive, proceed to early laparoscopic cholecystectomy within 7-10 days of symptom onset. 1, 2, 3

Why This Is Urgent

• Acute cholecystitis is the most frequent complication of gallstone disease and may be life-threatening; timely diagnosis is essential for proper treatment 1
• At 4 days of symptoms (right upper quadrant pain, nausea, vomiting), you are already within the critical window where complications like gangrenous cholecystitis, perforation, or gallbladder empyema can develop 2
• Clinical history and physical examination alone do not provide sufficient diagnostic certainty—imaging is mandatory 1

Immediate Diagnostic Algorithm

First-Line Imaging: Abdominal Ultrasound

• Ultrasound is the first choice of investigation for right upper quadrant pain with 96% accuracy for detecting gallstones 1, 2
• Key findings to look for: gallstones, gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy sign (focal tenderness when probe presses on gallbladder) 1, 2, 3
• Ultrasound also evaluates for bile duct dilation and can identify alternative diagnoses 2

If Ultrasound Is Negative But Suspicion Remains High

• Proceed to Tc-99m cholescintigraphy (HIDA scan), which has superior sensitivity (97%) and specificity (90%) for acute cholecystitis compared to ultrasound 2
• HIDA scan is particularly useful when ultrasound is equivocal but clinical presentation strongly suggests biliary disease 2, 3
• MRI with MRCP is an alternative with 85-100% sensitivity and 90% specificity, especially useful for evaluating bile duct stones 2

Symptom Management While Awaiting Evaluation

For Nausea and Vomiting

• Metoclopramide 10 mg IV/IM is effective for acute nausea and vomiting, administered slowly over 1-2 minutes 4
• Alternative antiemetics include prochlorperazine, ondansetron, or haloperidol if metoclopramide is contraindicated 1
• If nausea persists despite initial treatment, administer antiemetics around the clock rather than as-needed 1

Pain Control

• Appropriate analgesia should be provided, though note that pain medication may reduce the reliability of the sonographic Murphy sign 1

Treatment Based on Diagnosis

If Acute Cholecystitis Is Confirmed

• Early laparoscopic cholecystectomy within 7-10 days of symptom onset is the recommended treatment 3
• For uncomplicated cases: one-shot antibiotic prophylaxis with no post-operative antibiotics needed 3
• For complicated cholecystitis: Amoxicillin/Clavulanate 2g/0.2g IV every 8 hours for 4 days in immunocompetent patients 3
• Immunocompromised or critically ill patients require up to 7 days of antibiotics 3

Critical Pitfalls to Avoid

• Do not delay imaging beyond today—at 4 days, you are at significant risk for complications that dramatically increase morbidity and mortality 1, 2
• Do not rely on CT as first-line imaging—it has only 75% sensitivity for gallstones and is not the appropriate initial test 2
• Do not dismiss the diagnosis if sonographic Murphy sign is absent, especially if you've taken pain medication, as it has low specificity and its absence is unreliable 1
• Be aware that in critically ill patients, gallbladder abnormalities can occur without true cholecystitis, limiting ultrasound usefulness 1, 2

Alternative Diagnoses to Consider

While acute cholecystitis is the primary concern with your symptom duration and presentation, ultrasound will also evaluate for 2, 5:

• Choledocholithiasis (bile duct stones)
• Hepatic pathology
• Peptic ulcer disease complications
• Pancreatitis

The key message: Get an abdominal ultrasound immediately—do not wait another day with 4 days of right upper quadrant pain and vomiting. 1, 2