What is the cause of chronic right upper abdominal pain lasting up to 2 hours in a patient with a history of taking Restorolax (polyethylene glycol) and experiencing pain after bowel movements?

Chronic Right Upper Quadrant Pain Lasting Up to 2 Hours

Direct Answer

Order a right upper quadrant ultrasound immediately as your first-line diagnostic test, followed by a cholecystokinin-augmented HIDA scan with gallbladder ejection fraction calculation if the ultrasound is negative or equivocal. 1, 2

Diagnostic Algorithm

Step 1: Initial Imaging with RUQ Ultrasound

• Ultrasound is rated 9/9 (usually appropriate) by the American College of Radiology for RUQ pain evaluation and achieves 96% accuracy for gallbladder pathology without radiation exposure. 1, 2, 3
• The ultrasound must specifically assess for gallstones, gallbladder wall thickening, bile duct dilatation, and hepatic abnormalities. 1, 2
• This intermittent 2-hour pain pattern is classic for biliary colic, which typically presents as postprandial episodes of RUQ pain. 1

Step 2: Concurrent Laboratory Evaluation

• Order liver function tests including GGT, alkaline phosphatase, AST/ALT, total and direct bilirubin, and complete blood count alongside the ultrasound. 1, 2
• GGT elevates earlier and persists longer than alkaline phosphatase in cholestatic disorders, helping confirm hepatobiliary origin of the pain. 1, 2

Step 3: If Ultrasound is Negative or Equivocal

This is the critical decision point for your patient with chronic intermittent pain:

• Order cholecystokinin-augmented cholescintigraphy (HIDA scan) with gallbladder ejection fraction calculation to diagnose biliary dyskinesia or biliary hyperkinesia as the cause of chronic intermittent pain. 1
• A low ejection fraction (<35%) supports the diagnosis of chronic gallbladder disease or biliary dyskinesia in patients with typical biliary-type pain. 1
• Biliary hyperkinesia (GBEF >80-85%) is an overlooked cause of intermittent RUQ pain that presents identically to biliary dyskinesia but with excessive gallbladder contractility. 4

Step 4: Alternative Advanced Imaging if Needed

• If you suspect bile duct pathology or partial biliary obstruction, order MRI with MRCP, which has 85-100% sensitivity and 90% specificity for detecting choledocholithiasis and provides superior visualization of the entire biliary tree. 5, 1
• MRCP is particularly valuable for identifying partial biliary obstruction, biliary strictures, and sphincter of Oddi dysfunction that can cause intermittent symptoms mimicking chronic cholecystitis. 1

Critical Clinical Considerations

Pain Pattern Recognition

• The 2-hour duration and intermittent nature strongly suggest functional gallbladder disease (biliary dyskinesia or hyperkinesia) rather than acute cholecystitis. 1, 4
• Pain occurring after bowel movements may represent referred pain from gallbladder contraction triggered by postprandial hormonal responses. 4

Common Diagnostic Pitfalls to Avoid

• Do not order CT as initial imaging for chronic RUQ pain—CT has only ~75% sensitivity for gallstones, exposes patients to unnecessary radiation, and is inferior to ultrasound for gallbladder pathology. 1, 2
• Do not skip ultrasound and proceed directly to MRI or CT unless the patient is hemodynamically unstable or has specific contraindications. 2
• Recognize that many patients with normal ultrasound findings have functional gallbladder disorders that require HIDA scan for diagnosis. 4, 6

Therapeutic Implications

• Laparoscopic cholecystectomy provides significant symptomatic relief in patients with biliary dyskinesia (low GBEF) or biliary hyperkinesia (high GBEF) who have reproducible biliary-type pain. 4
• Surgical intervention should be considered when pain causes significant distress and impairs quality of life, even with normal baseline imaging. 4

Important Caveat About HIDA Scan Interpretation

• While HIDA scans with abnormal ejection fractions can identify functional gallbladder disease, the diagnostic value has limitations because this entity represents a variety of processes including inflammation, gallbladder dysmotility, and functional disorders. 6
• However, in patients with reproducible biliary-type pain and abnormal GBEF (either low or high), cholecystectomy outcomes are generally favorable. 4