What is the appropriate workup for a patient presenting with right upper abdominal pain that occasionally involves the left upper abdomen?

Workup for Right Upper Abdominal Pain with Occasional Left Upper Abdominal Involvement

Begin with abdominal ultrasonography as your first-line imaging study after obtaining initial laboratory tests including CBC, liver function tests, pancreatic enzymes, and a pregnancy test in all females of reproductive age. 1

Initial Laboratory Evaluation

Obtain the following tests immediately:

• Complete blood count (CBC) to assess for leukocytosis indicating infection or inflammation 1, 2
• Liver function tests (LFTs) including ALT, AST, alkaline phosphatase, GGT, and bilirubin to evaluate hepatobiliary disease 1, 2
• Pancreatic enzymes (amylase and lipase) to rule out pancreatitis, which commonly causes both right and left upper quadrant pain 1, 2
• Pregnancy test for all females of reproductive age before any imaging to prevent unnecessary radiation exposure and identify ectopic pregnancy 1, 3
• Urinalysis to evaluate for renal stones or infection 1
• Renal function tests (BUN, creatinine) to assess kidney function 3, 2

Critical pitfall: Never skip the pregnancy test in reproductive-age females before imaging—this prevents unnecessary radiation exposure and identifies potentially life-threatening ectopic pregnancy. 1, 3

Imaging Algorithm

First-Line Imaging: Abdominal Ultrasonography

Ultrasound is superior to CT as initial imaging because it provides excellent evaluation of gallbladder pathology (96% accuracy for gallstones), has no radiation exposure, is readily available, and can identify liver abnormalities and other causes of upper abdominal pain. 4, 1

Ultrasound effectively evaluates:

• Right upper quadrant sources: Gallbladder pathology (acute cholecystitis, cholelithiasis), liver abnormalities, and hepatobiliary tract disease 4, 3
• Left upper quadrant sources: Splenic pathology, pancreatic conditions, and left kidney abnormalities 3
• Additional findings: Gallbladder wall thickening, pericholecystic fluid, intrahepatic and extrahepatic bile duct dilation 4

The American College of Radiology assigns ultrasound the highest appropriateness rating (9/9) for right upper quadrant pain. 1

Second-Line Imaging: MRI with MRCP

If ultrasound is non-diagnostic and biliary disease remains suspected, MRI with MRCP is superior to CT for biliary sources of pain, with 85-100% sensitivity for cholelithiasis/choledocholithiasis and excellent visualization of the cystic duct and common bile duct. 1

MRI advantages over CT include:

• Better evaluation of hepatic and biliary abnormalities not characterized by ultrasound 4
• Superior detection of gallstones in the gallbladder neck, cystic duct, or common bile duct 4
• No radiation exposure, particularly important in younger patients 1, 3
• Excellent visualization of the pancreas, relevant given your left upper quadrant involvement 1

Third-Line Imaging: CT Abdomen with Contrast

CT abdomen with contrast has an appropriateness rating of only 6/9 and should not be first-line due to radiation exposure, especially in younger patients. 1, 3

Use CT when:

• Ultrasound is negative but acute cholecystitis is still suspected (CT may demonstrate findings missed by ultrasound) 4
• Complicated cholecystitis is suspected (emphysematous, hemorrhagic, gangrenous, or perforated) 4
• Alternative diagnoses need evaluation after negative ultrasound and MRI 3

Important caveat: CT without IV contrast misses critical findings like wall enhancement and adjacent liver parenchymal hyperemia, which are early signs of acute cholecystitis. 4

Avoid Conventional Radiography

Plain X-rays have minimal diagnostic value for upper abdominal pain and should not be routinely ordered. 1, 3

Clinical Decision Points

If laboratory values show no elevation in leukocyte count or C-reactive protein: Re-evaluate the patient after 12 hours before proceeding with imaging. 5

If elevated amylase and lipase are present: This strongly suggests pancreatitis, which commonly causes both right and left upper quadrant pain and explains your bilateral presentation. 2

If ultrasound confirms acute cholecystitis: Treatment should be initiated immediately without additional imaging. 1

Common pitfall: Do not rely solely on laboratory tests without appropriate imaging when indicated—this leads to delayed diagnosis. 3, 2

Special Considerations for Bilateral Pain

The involvement of both right and left upper quadrants suggests:

• Pancreatitis as a primary consideration (pancreatic inflammation can radiate to both upper quadrants) 2
• Hepatobiliary disease with pancreatic involvement 2
• Splenic pathology extending from the left upper quadrant 2

This bilateral pattern makes pancreatic enzyme evaluation particularly critical in your initial workup. 2