What are the causes and treatments of right upper back pain?

Right Upper Back Pain: Causes and Management

Primary Diagnostic Consideration

Right upper back pain most commonly originates from biliary disease, particularly acute cholecystitis, and ultrasound is the mandatory first imaging study. 1

Initial Diagnostic Approach

Key Clinical Features to Assess

• Fever and elevated white blood cell count suggest acute cholecystitis requiring urgent evaluation 1
• Right upper quadrant tenderness with radiation to the back indicates biliary pathology 1
• Nausea, vomiting, and anorexia accompanying the pain support cholecystitis 1
• Absence of jaundice keeps focus on gallbladder rather than bile duct obstruction 1

Red Flags Requiring Immediate Imaging

• Progressive neurologic deficits (if pain is truly posterior/spinal) 2
• History of cancer with new-onset pain 2
• Urinary retention or saddle anesthesia (cauda equina syndrome) 2
• Unexplained weight loss in patients over 50 years 2

Imaging Algorithm

First-Line: Ultrasound Abdomen

Ultrasound is the initial imaging modality of choice with 96% accuracy for detecting gallstones. 1

• Identifies gallstones, sludge, polyps, and masses 1
• Assesses gallbladder wall thickening and pericholecystic fluid 1
• Sonographic Murphy sign (focal tenderness over gallbladder) has low specificity but supports diagnosis 1

Second-Line: When Ultrasound is Negative or Equivocal

If ultrasound is negative but clinical suspicion remains high, proceed to MRI with MRCP (preferred) or CT with IV contrast. 1

MRI with MRCP Advantages:

• 85-100% sensitivity for cholelithiasis/choledocholithiasis 1
• Superior visualization of cystic duct and common bile duct compared to ultrasound 1
• Differentiates acute from chronic cholecystitis based on T2 signal intensity 1
• Identifies alternative diagnoses including masses, strictures, and lymph nodes 1

CT with IV Contrast:

• Approximately 75% sensitivity for gallstone detection 1
• Detects complications: gangrene, gas formation, hemorrhage, perforation 1
• Shows adjacent liver parenchymal hyperemia (early finding in acute cholecystitis) 1
• Useful for preoperative planning and predicting conversion to open cholecystectomy 1

Nuclear Medicine Cholescintigraphy

For chronic/recurrent right upper quadrant pain with negative ultrasound, Tc-99m cholescintigraphy with cholecystokinin can diagnose biliary dyskinesia and chronic gallbladder disease. 1

• Calculates gallbladder ejection fraction after cholecystokinin infusion 1
• Diagnoses partial biliary obstruction and sphincter of Oddi dysfunction 1
• Avoids pancreatitis risk associated with manometric evaluation 1

Alternative Diagnoses to Consider

Musculoskeletal Causes (If Pain is Truly Posterior)

For nonspecific back pain without biliary features, avoid routine imaging and focus on clinical assessment. 1, 2

• Muscle strain typically improves within 4-6 weeks 3
• Imaging only indicated for red flags, persistent symptoms beyond 12 weeks, or neurologic deficits 1, 2
• MRI is preferred over CT for suspected radiculopathy or spinal stenosis 1

Life-Threatening Emergencies

• Aortic dissection or rupturing abdominal aortic aneurysm 3
• Spinal epidural abscess or vertebral osteomyelitis 3
• Cauda equina syndrome (requires MRI and surgical decompression within 12 hours) 2

Management Strategy

For Confirmed Acute Cholecystitis

Surgical consultation for cholecystectomy is the definitive treatment. 1

• Laparoscopic approach is standard unless imaging predicts complications 1
• CT findings of absent wall enhancement or infundibular stone predict conversion to open surgery 1

For Chronic Cholecystitis or Biliary Dyskinesia

Cholecystectomy is indicated for symptomatic patients with low gallbladder ejection fraction (<35%) on cholescintigraphy. 1

For Musculoskeletal Pain (If Biliary Workup Negative)

Advise patients to remain active, provide self-care education, and start acetaminophen or NSAIDs. 1

• Avoid bed rest 1
• Consider muscle relaxants like cyclobenzaprine 5-10 mg three times daily for acute muscle spasm (use only 2-3 weeks) 4
• Add physical therapy, spinal manipulation, or acupuncture if no improvement with initial measures 1

Critical Pitfalls to Avoid

• Do not delay imaging in patients with fever and elevated WBC - acute cholecystitis can progress to gangrene and perforation 1
• Do not order CT without IV contrast for suspected cholecystitis - adjacent liver hyperemia cannot be detected and is an early diagnostic finding 1
• Do not routinely image nonspecific back pain - it increases costs without improving outcomes 1
• Do not miss cauda equina syndrome - surgical decompression must occur within 12 hours to optimize functional recovery 2