What is the next course of action for a patient with nausea, vomiting, and right upper quadrant (RUQ) pain, with no evidence of cholecystitis or liver abnormalities on ultrasound?

Next Steps for RUQ Pain with Negative Ultrasound

When ultrasound fails to demonstrate cholecystitis or liver abnormalities in a patient with nausea, vomiting, and RUQ pain, obtain a hepatobiliary scintigraphy (HIDA scan) if clinical suspicion for acute cholecystitis remains high, or proceed to CT abdomen with IV contrast to evaluate for alternative diagnoses and complications. 1, 2

Algorithmic Approach to Management

Step 1: Reassess Clinical Suspicion for Acute Cholecystitis

• High clinical suspicion persists (RUQ tenderness, positive Murphy's sign, elevated inflammatory markers): Proceed directly to HIDA scan 2

  • HIDA scan has 97% sensitivity and 90% specificity for acute cholecystitis 2
  • This is particularly critical because ultrasound can miss early acute cholecystitis when gallbladder wall thickening has not yet developed 2
  • Acalculous cholecystitis can present with negative ultrasound and CT, making HIDA scan essential when clinical suspicion remains high 3

• Moderate clinical suspicion or unclear diagnosis: Obtain CT abdomen with IV contrast 1

  • The 2024 IDSA guidelines specifically recommend CT as the next imaging modality when initial ultrasound is equivocal or non-diagnostic 1
  • CT with IV contrast can identify complications including gangrene, perforation, gas formation, and adjacent liver parenchymal hyperemia—an early finding in acute cholecystitis 1, 2

Step 2: Consider Alternative Diagnoses

CT abdomen with IV contrast is particularly valuable for identifying non-biliary causes of RUQ pain: 1, 4, 5

• Hepatic pathology (abscess, mass with capsular involvement)
• Pancreatic inflammation
• Renal pathology (pyelonephritis, nephrolithiasis)
• Gastrointestinal disorders (peptic ulcer disease, duodenitis)
• Vascular conditions
• Thoracic processes (pneumonia, pulmonary embolism)

Step 3: Advanced Imaging if Initial Studies Remain Non-Diagnostic

If both ultrasound and CT are negative but clinical suspicion persists, obtain MRI/MRCP: 1, 2

• MRCP has 85-100% sensitivity for cholelithiasis and choledocholithiasis 1
• MRI with gadolinium can distinguish acute from chronic cholecystitis based on T2 signal characteristics and wall enhancement patterns 2
• Particularly useful for detecting gallstones in the gallbladder neck, cystic duct, or common bile duct that may be missed on ultrasound 1

Critical Clinical Pearls

Common Pitfalls to Avoid

• Do not rely on absence of gallbladder wall thickening to exclude acute cholecystitis—early presentations may not show this finding 2
• Murphy's sign has low specificity and its absence is unreliable, especially if the patient received pain medication prior to examination 2, 6
• CT without IV contrast misses important findings such as wall enhancement and adjacent liver parenchymal hyperemia, which are early indicators of acute cholecystitis 1
• Delay in diagnosis of acalculous cholecystitis carries >50% mortality—maintain high index of suspicion even with negative imaging 3

When to Involve Surgery

Obtain early surgical consultation regardless of imaging results if: 2

• Patient has peritoneal signs suggesting perforation or gangrene
• Hemodynamic instability develops (as seen in septic presentations of AAC) 3
• Clinical deterioration occurs despite negative imaging

Laparoscopic cholecystectomy is the definitive treatment for acute cholecystitis and should be performed early to reduce complications and hospital stay. 2

Laboratory Evaluation Considerations

While no single laboratory test rules in or out cholecystitis 7, the following support further workup:

• Elevated alkaline phosphatase or bilirubin suggests biliary obstruction and warrants advanced imaging 1
• Marked leukocytosis with fever raises concern for empyema or complicated cholecystitis 2
• Indicators of inflammation and biliary stasis support the diagnosis of acute cholangitis 1