What could be causing worsening symptoms after eating, bad taste in the mouth, and right upper quadrant pain radiating to the left upper quadrant?

Clinical Presentation Suggests Biliary Disease

Your symptoms of right upper quadrant pain worsening after eating with a bad taste in mouth, radiating to the left upper quadrant, are most consistent with biliary pathology, particularly cholecystitis or choledocholithiasis, and require immediate ultrasound evaluation. 1, 2

Key Diagnostic Features

Symptom Pattern Analysis

• Postprandial worsening is highly characteristic of biliary disease, as fatty meals trigger gallbladder contraction against an obstructed cystic duct or gallstones 2, 3
• Bad taste in mouth can occur with biliary disease and has been documented as a presenting symptom in hepatobiliary pathology 1
• Pain radiation from RUQ to LUQ is atypical for simple biliary colic (which typically radiates to right shoulder/back), suggesting possible pancreatic involvement or complicated biliary disease 2, 3

Critical Red Flags to Assess

• Fever or elevated white blood cell count would indicate acute cholecystitis requiring urgent intervention 1
• Jaundice suggests choledocholithiasis or biliary obstruction 2
• Murphy's sign (inspiratory arrest during RUQ palpation) is highly specific for acute cholecystitis 2, 3

Immediate Diagnostic Algorithm

First-Line Imaging

Obtain abdominal ultrasound immediately as the primary diagnostic test, with 96% accuracy for detecting gallstones and ability to identify gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy sign 1, 2, 3

Essential Laboratory Tests

• Complete blood count to assess for leukocytosis indicating infection 2, 3
• Liver function tests (ALT, AST, alkaline phosphatase, GGT, bilirubin) to evaluate hepatobiliary disease 2
• Pancreatic enzymes (amylase and lipase) given the LUQ radiation pattern suggesting possible pancreatitis 2, 3

Second-Line Imaging When Ultrasound is Equivocal

• CT abdomen with IV contrast should be performed if ultrasound is nondiagnostic or complications are suspected, as it detects gallbladder wall enhancement, adjacent liver parenchymal hyperemia, and complications like perforation or gas formation 1, 3
• MRI with MRCP provides superior evaluation of the biliary tree with 85-100% sensitivity for choledocholithiasis and is particularly useful when common bile duct stones are suspected 1

Critical Pitfalls to Avoid

Imaging Errors

• Never skip ultrasound and proceed directly to CT, as ultrasound provides rapid, cost-effective diagnosis without radiation exposure 3
• Do not order CT without IV contrast for suspected cholecystitis, as wall enhancement and liver hyperemia cannot be detected without contrast 1, 3
• CT has only 75% sensitivity for gallstones, so negative CT does not exclude cholelithiasis 1

Diagnostic Considerations

• Negative ultrasound does not exclude biliary disease - cholescintigraphy has 96% sensitivity and 90% specificity for acute cholecystitis, superior to ultrasound's 81% and 83% 1
• Consider non-biliary causes if imaging is negative, including peptic ulcer disease, hepatitis, pancreatitis, or referred pain from pulmonary pathology 1, 4, 5
• The broad differential for nonlocalized abdominal pain includes intestinal disorders, liver masses, and even thoracic pathology 1

When Fever is Present

If you develop fever, this constitutes a surgical emergency requiring immediate evaluation, as acute cholecystitis with fever has high morbidity and may progress to gangrene, perforation, or sepsis 1