What is the diagnosis and treatment for a middle-aged adult with a history of gallstones, presenting with right abdominal pain radiating to the back, nausea, and gas?

Diagnosis and Management of Right Upper Quadrant Pain with Gallstone History

Most Likely Diagnosis

This presentation is most consistent with biliary colic or acute cholecystitis, given the history of gallstones, right upper quadrant pain radiating to the back, and associated nausea. 1, 2, 3

Differential Diagnosis to Consider

The pain pattern with radiation to the back raises several important diagnostic possibilities:

• Biliary colic - episodic severe pain from gallstone obstruction of the cystic duct, typically lasting hours and radiating to the right shoulder or back 1, 2
• Acute cholecystitis - persistent inflammation of the gallbladder, often with fever and positive Murphy's sign 1, 3
• Choledocholithiasis - bile duct stones causing obstruction, which may present with jaundice and elevated liver enzymes 4, 3
• Gallstone pancreatitis - severe pain radiating to the upper back that builds to a steady level, lasts hours to a full day, and is associated with nausea/vomiting 2
• Chronic cholecystitis - recurrent inflammation associated with gallstones in 95% of cases 5

Critical Physical Examination Findings

Assess for Murphy's sign by palpating the right upper quadrant during inspiration - pain with this maneuver is highly suggestive of acute cholecystitis. 1, 3

Additional examination components:

• Check vital signs for fever, tachycardia, or hypotension indicating infection or sepsis 1
• Assess for right upper quadrant tenderness 1
• Examine for hepatomegaly or splenomegaly 1
• Look for peritoneal signs suggesting complications like perforation 1
• Evaluate for jaundice indicating possible bile duct obstruction 1

Essential Laboratory Testing

Order a complete blood count, comprehensive metabolic panel including liver function tests (ALT, AST, alkaline phosphatase, GGT, bilirubin), and pancreatic enzymes (amylase and lipase). 1, 4

• Leukocytosis suggests infection or inflammation 1
• Elevated alkaline phosphatase and bilirubin indicate biliary obstruction 4
• Elevated lipase/amylase (>3x upper limit of normal) confirms pancreatitis 1
• For women of reproductive age, obtain a pregnancy test to rule out ectopic pregnancy 1

Diagnostic Imaging Algorithm

First-Line Imaging

Obtain right upper quadrant ultrasound immediately as the initial imaging modality - it has 96% accuracy for detecting gallstones and can identify acute cholecystitis. 1, 4, 3

Ultrasound advantages:

• Detects gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy sign 1
• Identifies bile duct dilatation with specificities of 71-97% for mechanical obstruction 4
• No radiation exposure, portable, and cost-effective 4, 6
• Can detect alternative diagnoses including cirrhosis (sensitivity 65-95%) 4

Advanced Imaging When Ultrasound is Negative or Equivocal

If ultrasound is negative or equivocal and biliary disease remains suspected, proceed directly to MRCP (MRI with magnetic resonance cholangiopancreatography). 5, 4

MRCP is superior for:

• Detecting choledocholithiasis with sensitivity of 85-100%, specificity of 90%, and accuracy of 89-90% 5, 4
• Visualizing the common bile duct and cystic duct better than ultrasound 5, 4
• Identifying the level and cause of biliary obstruction with 91-100% accuracy 4
• Detecting gallstones in the gallbladder neck, cystic duct, or common bile duct 5

Role of HIDA Scan

Reserve HIDA scan (cholescintigraphy) for suspected acute cholecystitis when ultrasound is equivocal, particularly with fever and elevated WBC count. 5, 4, 3

HIDA scan is specifically indicated for:

• Acalculous cholecystitis (imaging examination of choice) 5, 4
• Chronic gallbladder disease or biliary dyskinesia with gallbladder ejection fraction calculation 5, 4
• Low-grade, partial, or intermittent biliary obstruction 5

When to Use CT

CT with IV contrast should be reserved for critically ill patients with suspected complications such as emphysematous cholecystitis, gallbladder perforation, or abscess formation. 5, 4

CT limitations:

• Only 75% sensitivity for detecting gallstones (many are non-calcified) 5, 4
• Not first-line for suspected biliary causes of right upper quadrant pain 5
• Exposes patient to radiation without clear advantage over ultrasound initially 4

CT advantages when complications suspected:

• Detects gallbladder wall thickening, pericholecystic inflammation, gas formation, and hemorrhage 5
• Adjacent liver parenchymal hyperemia (requires IV contrast) is an early finding in acute cholecystitis 5
• Can reveal gangrene, perforation, and abscess formation 5

Treatment Approach

Pain Management

Administer nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line treatment for biliary colic pain - they are safe and effective. 3, 7

• Spasmolytics can be added for additional relief 7
• Opioids may be used for severe acute pain 7

Definitive Management Based on Diagnosis

For symptomatic gallstones (biliary colic), recommend laparoscopic cholecystectomy as the treatment of choice, since the risk of recurrence or complications increases over time. 3, 7

For acute cholecystitis, perform early laparoscopic cholecystectomy within 24 hours of hospital admission. 7, 8

For choledocholithiasis with bile duct obstruction and/or cholangitis, perform endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy within 24-72 hours. 8

• ERCP should only be performed after non-invasive imaging confirms biliary obstruction requiring intervention, due to risks of pancreatitis and perforation 4

For gallstone pancreatitis with evidence of ongoing bile duct obstruction and/or cholangitis, perform ERCP within 24-72 hours of symptom onset. 8

Important Clinical Caveats

• The sonographic Murphy sign has relatively low specificity and is unreliable if the patient received pain medication prior to imaging 4
• Up to 80% of patients with gallstones remain asymptomatic throughout their lifetime 3, 9, 8
• Pain from gallstone pancreatitis characteristically radiates to the upper back, builds to a steady level rather than being colicky, lasts hours to a full day, and is not relieved by bowel movements or antacids 2
• Over one-third of patients initially thought to have acute cholecystitis actually have right upper quadrant pain from other causes 6
• Do not order HIDA scan as the primary test for elevated liver function tests and right upper quadrant pain unless acute cholecystitis is the primary clinical concern 4
• Noncontrast CT has very limited value for evaluating suspected biliary disease 5