What is the appropriate evaluation and management for a patient presenting with right upper quadrant pain?

Evaluation and Management of Right Upper Quadrant Pain

Initial Assessment

Begin with focused history and physical examination targeting life-threatening conditions, followed by abdominal ultrasound as the first-line imaging modality for suspected biliary disease. 1, 2, 3

History Taking

Obtain specific pain characteristics including:

• Onset, duration, quality, severity, and radiation pattern (biliary colic typically presents as episodic severe pain radiating to right shoulder or back) 1
• Associated symptoms: fever, nausea, vomiting, anorexia, jaundice, changes in bowel habits, or weight loss 1
• Medication history: all drugs taken within 6 weeks including prescription, over-the-counter, herbal medicines, and supplements 1
• Past medical history: prior biliary disease, biliary surgery, liver disease, or hereditary cholestatic disorders 1
• Alcohol intake to assess for alcoholic liver disease 1

Physical Examination

Perform systematic examination focusing on:

• Vital signs: fever, tachycardia, or hypotension suggesting infection or sepsis 1
• Murphy's sign: pain with inspiration during RUQ palpation (highly suggestive of acute cholecystitis) 1, 3
• RUQ tenderness 1, 2
• Hepatomegaly or splenomegaly 1
• Abdominal distension, masses, or peritoneal signs 1

Laboratory Testing

Order the following initial laboratory studies:

• Complete blood count (CBC) to assess for leukocytosis indicating infection or inflammation 1, 3
• Liver function tests (ALT, AST, alkaline phosphatase, GGT, bilirubin) to evaluate hepatobiliary disease 1, 3
• Pancreatic enzymes (amylase and lipase) to rule out pancreatitis 1, 3
• Pregnancy test for all women of reproductive age before any imaging to rule out ectopic pregnancy and avoid unnecessary radiation exposure 1, 2, 3
• Urinalysis to evaluate for renal stones or infection 2, 3

Diagnostic Imaging Algorithm

First-Line Imaging

Abdominal ultrasound is the initial imaging modality of choice with the highest appropriateness rating (9/9) and 96% accuracy for diagnosing gallstones. 4, 1, 2, 3, 5

Ultrasound advantages include:

• No radiation exposure (critical in young patients and reproductive-age females) 2, 3, 5
• High sensitivity and specificity for gallbladder pathology 6, 5
• Identifies gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy sign 1
• Readily available and cost-effective 3, 5

Second-Line Imaging Options

If ultrasound is inconclusive or additional evaluation is needed:

• Cholescintigraphy (HIDA scan) for suspected acute cholecystitis with appropriateness rating 6/9 2, 3
• MRI/MRCP is superior to CT for biliary sources with 85-100% sensitivity for cholelithiasis/choledocholithiasis and excellent visualization of cystic and common bile ducts 3
• CT abdomen with contrast (appropriateness rating 6/9) may demonstrate acute cholecystitis if ultrasound is negative, but should not be first-line due to radiation exposure 2, 3

Note: While one retrospective study suggested CT is noninferior to ultrasound for cholecystitis diagnosis and better identifies nongallbladder pathology 7, current guidelines consistently prioritize ultrasound first due to lack of radiation exposure and excellent diagnostic accuracy for biliary disease 4, 1, 2, 3, 5.

Differential Diagnosis Considerations

Biliary Causes

• Acute cholecystitis (most common cause of acute RUQ pain) 6, 8
• Cholelithiasis 1, 3
• Choledocholithiasis 3

Hepatic Causes

• Hepatitis 8
• Hepatic abscess 8
• Hepatomegaly from various etiologies 1

Non-Gastrointestinal Causes

• Right lower lobe pneumonia (can present with RUQ pain and referred pain) 9, 8
• Cardiac causes: inferior wall myocardial infarction can present with epigastric/RUQ pain 4
• Musculoskeletal: rib fracture, costochondritis 8
• Renal: nephrolithiasis, pyelonephritis 8

Critical Pitfalls to Avoid

• Never skip pregnancy testing in reproductive-age females before imaging to prevent unnecessary radiation exposure and identify ectopic pregnancy 1, 2, 3
• Do not use CT as first-line imaging in younger patients when ultrasound is highly effective and avoids radiation 2, 3
• Avoid relying solely on laboratory tests without appropriate imaging when indicated, as this can result in missed diagnoses 2
• Do not order conventional radiography (plain X-rays) as they have minimal diagnostic value for RUQ pain 3
• Broaden differential diagnosis after multiple negative hepatobiliary tests and consider referred pain from thoracic or spinal sources 9
• In office settings with clinical evidence of acute cholecystitis or life-threatening causes, transport urgently to ED by EMS rather than delaying for additional testing 4

Management Based on Findings

If Acute Cholecystitis Confirmed

• Urgent surgical consultation for cholecystectomy (treatment of choice for uncomplicated disease) 6
• Consider percutaneous cholecystostomy in critically ill patients as bridge to surgery 4

If Ultrasound Negative but High Clinical Suspicion

• Proceed to MRI/MRCP for superior biliary visualization 3
• Consider cholescintigraphy if gallbladder dysfunction suspected 2, 3

If Complications Suspected

• CT imaging to confirm extent and nature of complications (perforation, abscess) 6
• Supportive measures initially with elective cholecystectomy later for complicated cases 6