What is the initial management for a patient presenting with right upper quadrant pain?

Management of Right Upper Quadrant Pain

Obtain an abdominal ultrasound immediately as the first-line imaging study for any patient presenting with right upper quadrant pain. 1, 2

Initial Clinical Assessment

History Taking

• Document pain characteristics: onset, duration, quality, severity, and radiation (biliary colic typically radiates to the right shoulder or back) 2
• Record associated symptoms including fever, nausea, vomiting, jaundice, and changes in bowel habits 2
• Obtain medication history from the past 6 weeks, including prescription drugs, over-the-counter medications, herbal supplements 2
• Document alcohol intake and any history of biliary disease, prior biliary surgery, or liver disease 2

Physical Examination

• Check vital signs for fever, tachycardia, or hypotension suggesting infection or sepsis 2
• Assess for right upper quadrant tenderness 1, 2
• Elicit Murphy's sign (inspiratory arrest during RUQ palpation), which is highly suggestive of acute cholecystitis 2, 1
• Examine for hepatomegaly, splenomegaly, abdominal distension, masses, or peritoneal signs 2

Laboratory Testing

• Complete blood count to assess for leukocytosis 2
• Liver function tests: ALT, AST, alkaline phosphatase, GGT, and bilirubin 2
• Pancreatic enzymes (amylase and lipase) to exclude pancreatitis 2
• Pregnancy test for all women of reproductive age before imaging 1, 2

Imaging Algorithm

First-Line: Abdominal Ultrasound

Ultrasound is the primary imaging modality with 96% accuracy for diagnosing gallstones and should be performed first in all patients with RUQ pain. 1, 2, 3

Ultrasound can identify:

• Gallstones and gallbladder wall thickening 2, 1
• Pericholecystic fluid and sonographic Murphy sign 2, 1
• Biliary dilatation 3
• Alternative diagnoses beyond gallbladder disease (hepatic, pancreatic, renal, vascular pathology) 4

Second-Line Imaging (If Ultrasound is Equivocal or Nondiagnostic)

CT abdomen with IV contrast should be performed when:

• Ultrasound findings are equivocal 1
• Complications of cholecystitis are suspected (gangrene, perforation, gas formation, hemorrhage) 1
• Alternative diagnoses need to be excluded 1
• The patient is critically ill 1

CT provides superior detection of:

• Gallbladder wall enhancement and adjacent liver parenchymal hyperemia (requires IV contrast) 1
• Complications including perforation, gas formation, and intraluminal hemorrhage 1
• Alternative abdominal pathology 4

Cholescintigraphy (Tc-99m hepatobiliary scan) should be considered when:

• Ultrasound and clinical findings remain equivocal for acute cholecystitis 1
• Higher sensitivity and specificity for acute cholecystitis are needed (gallbladder nonvisualization indicates cystic duct obstruction) 1

MRI abdomen with MRCP may be used when:

• Other imaging tests are equivocal 1
• The patient is difficult to examine with ultrasound 1
• Detailed evaluation of the biliary tree is needed (MRI has excellent accuracy for bile duct visualization and stone detection) 1
• Avoiding ionizing radiation is important 5

Common Pitfalls

• Do not skip ultrasound and proceed directly to CT, as ultrasound provides rapid, cost-effective diagnosis and avoids radiation exposure 1, 2
• Do not order CT without IV contrast for suspected cholecystitis, as important findings like wall enhancement and liver hyperemia cannot be detected without contrast 1
• Remember that over one-third of patients with RUQ pain do not have acute cholecystitis, so ultrasound should evaluate all visible structures for alternative diagnoses 3, 4
• CT has only 75% sensitivity for gallstones, so negative CT does not exclude cholelithiasis 1
• Consider viral infections (such as Epstein-Barr virus) in patients with RUQ pain, tonsillar exudates, and lymphocytosis, as this mimics bacterial cholecystitis but requires different management 6