What is the appropriate evaluation and management for a 30-year-old female with right upper quadrant (RUQ) pain and hematuria?

Evaluation and Management of RUQ Pain with Hematuria in a 30-Year-Old Female

Begin with right upper quadrant ultrasound as the first-line imaging study, followed by urinalysis and complete laboratory workup to simultaneously evaluate both the biliary system and urinary tract. 1

Initial Diagnostic Approach

The combination of RUQ pain and hematuria in a young woman requires evaluation of both hepatobiliary and genitourinary systems, as these symptoms may represent:

• Overlapping pathologies from separate organ systems
• A single process affecting both systems (e.g., trauma, systemic disease)
• Referred pain patterns

Immediate Clinical Assessment

Obtain a focused history addressing:

• Pain characteristics: onset, duration, quality, radiation to right shoulder or back (suggesting biliary origin), or flank (suggesting renal origin) 1
• Trauma history: even minor trauma can cause significant injury to anomalous kidneys or precipitate biliary disease 2
• Associated symptoms: fever, nausea, vomiting, jaundice, dysuria, or urinary frequency 1
• Menstrual history and pregnancy status (mandatory before imaging) 1

Physical examination must include:

• Murphy's sign assessment (highly suggestive of acute cholecystitis if positive) 1
• Costovertebral angle tenderness (suggests renal pathology) 3
• Peritoneal signs indicating surgical emergency 1

Laboratory Testing

Order the following tests concurrently with imaging:

• Urinalysis with microscopy to quantify hematuria and assess for infection, casts, or crystals 3
• Complete blood count to detect leukocytosis or anemia 1
• Comprehensive metabolic panel including liver function tests (ALT, AST, alkaline phosphatase, bilirubin) 1
• Lipase to exclude pancreatitis 1
• Urine pregnancy test (mandatory in all reproductive-age women) 1

Imaging Algorithm

Step 1: Right Upper Quadrant Ultrasound (First-Line)

Ultrasound is rated 9/9 (usually appropriate) by the American College of Radiology and provides 96% accuracy for detecting gallstones and biliary pathology. 1, 4

Ultrasound advantages in this scenario:

• Evaluates gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy sign 1
• Assesses for hepatic lesions, subcapsular hematomas, or free fluid 4
• Visualizes kidneys for hydronephrosis, masses, or stones 5
• Radiation-free, rapid, and cost-effective 1

Step 2: Renal Ultrasound or CT Based on Initial Findings

If hematuria is gross or urinalysis shows >50 RBCs/hpf, proceed with dedicated urinary tract imaging:

• Non-contrast CT abdomen/pelvis (CT urography protocol) is the gold standard for evaluating urolithiasis and has superior sensitivity for detecting renal trauma 2
• Contrast-enhanced CT is required if renal injury is suspected, with delayed imaging to assess for collecting system disruption 2

If RUQ ultrasound is equivocal or shows concerning findings:

• CT abdomen with IV contrast provides superior detection of gallbladder wall enhancement, adjacent liver parenchymal hyperemia, and complications (perforation, hemorrhage, gas formation) 2, 1
• MRI with MRCP offers 85-100% sensitivity for biliary pathology when CT findings remain unclear 2, 1

Step 3: Advanced Imaging When Initial Studies Are Non-Diagnostic

If both ultrasound and initial CT are equivocal:

• Tc-99m cholescintigraphy for suspected acalculous cholecystitis or chronic cholecystitis with normal ultrasound 2
• MRI abdomen with MRCP for comprehensive biliary tree evaluation (90% specificity) 2, 1

Risk Stratification for Hematuria

Microscopic hematuria (most common presentation) requires:

• Evaluation for benign causes: urinary tract infection, urolithiasis, or menstruation 3
• If no benign cause identified, referral to urology for cystoscopy and upper tract imaging (risk of malignancy exists even with microscopic hematuria) 3, 6

Gross hematuria (>10% malignancy risk) mandates:

• Urgent urology referral 3
• Contrast-enhanced CT urography as the preferred imaging modality 2

Common Pitfalls to Avoid

Do not skip ultrasound and proceed directly to CT, as ultrasound provides rapid diagnosis without radiation exposure and has superior sensitivity for gallstones compared to CT (96% vs 75%) 1

Do not order CT without IV contrast for suspected cholecystitis, as critical findings like wall enhancement and liver hyperemia cannot be detected without contrast 1

Do not dismiss isolated microscopic hematuria without follow-up, as 36% of men and only 8% of women with hematuria receive appropriate urologic referral despite guideline recommendations 6

Do not assume a single diagnosis explains both symptoms—evaluate each system independently until a unifying diagnosis is confirmed 5

Disposition and Follow-Up

Immediate ED referral is indicated for:

• Fever with leukocytosis suggesting acute cholecystitis or pyelonephritis 1
• Hemodynamic instability 4
• Peritoneal signs 1
• Gross hematuria with clots or acute urinary retention 3

Outpatient management is appropriate for:

• Mild symptoms with normal vital signs 4
• Microscopic hematuria without systemic symptoms 3
• Negative or benign imaging findings requiring only clinical follow-up 1