What should I do if I have right upper quadrant abdominal pain?

Right Upper Quadrant Abdominal Pain: Immediate Diagnostic Approach

If you have right upper quadrant (RUQ) abdominal pain, you should undergo ultrasound imaging immediately as the first-line diagnostic test, as this is the most appropriate initial imaging modality recommended by the American College of Radiology for evaluating RUQ pain. 1

Initial Clinical Assessment

When presenting with RUQ pain, your physician should specifically evaluate for:

• Acute cholecystitis signs: Murphy's sign (pain with palpation during deep inspiration), fever, and abdominal tenderness 1
• Palpable gallbladder mass: This indicates complicated acute cholecystitis requiring urgent intervention 1
• Jaundice: Suggests biliary obstruction requiring advanced imaging 2, 3
• Severity markers: Fever, elevated white blood cell count, and elevated liver function tests guide management decisions 1

Imaging Algorithm

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

Ultrasound is the investigation of choice for suspected acute cholecystitis and should be performed first. 1

Ultrasound will identify:

• Gallstones with 96% accuracy 2, 3
• Gallbladder wall thickening and edema 1
• Pericholecystic fluid (fluid around the gallbladder) 1
• Distended gallbladder 1
• Sonographic Murphy's sign 1
• Bile duct dilatation indicating possible obstruction 2, 3

Step 2: Advanced Imaging Based on Ultrasound Findings

If ultrasound is negative or equivocal, proceed to MRCP (Magnetic Resonance Cholangiopancreatography) for comprehensive evaluation of the biliary tree. 2, 3

MRCP is superior because:

• Sensitivity of 85-100% and specificity of 90% for detecting bile duct stones and obstruction 2
• Accuracy of 91-100% for identifying the level and cause of biliary obstruction 2
• Better visualization of the common bile duct and cystic duct compared to ultrasound 2
• No radiation exposure unlike CT 1

Step 3: CT Imaging (Reserved for Specific Situations)

CT with IV contrast should only be ordered if you are critically ill, have atypical presentation, or complications are suspected (such as perforation, abscess, or emphysematous cholecystitis). 1

CT is not appropriate as first-line imaging because:

• Lower sensitivity (39-75%) for detecting gallstones compared to ultrasound 2
• Unnecessary radiation exposure without diagnostic advantage 1
• Many gallstones are not visible on CT (up to 80% are noncalcified) 2

Treatment Pathways Based on Diagnosis

Uncomplicated Acute Cholecystitis

Early laparoscopic cholecystectomy within 7-10 days of symptom onset is the definitive treatment. 1

• One-shot antibiotic prophylaxis if early intervention performed 1
• No post-operative antibiotics needed if source control is adequate 1

Complicated Cholecystitis

Laparoscopic cholecystectomy plus antibiotic therapy is required. 1

For immunocompetent, non-critically ill patients:

• Amoxicillin/Clavulanate 2g/0.2g every 8 hours 1
• Duration: 4 days if source control is adequate 1

For critically ill or immunocompromised patients:

• Piperacillin/tazobactam 6g/0.75g loading dose, then 4g/0.5g every 6 hours 1
• Duration: up to 7 days based on clinical conditions and inflammation indices 1

Bile Duct Stones (Choledocholithiasis)

If MRCP confirms bile duct stones with elevated liver function tests, proceed to therapeutic ERCP (Endoscopic Retrograde Cholangiopancreatography). 2

• ERCP should only be performed after non-invasive imaging confirms biliary obstruction requiring intervention 2
• Do not use ERCP as a diagnostic test due to risks of pancreatitis and perforation 2

Critical Pitfalls to Avoid

• Do not order HIDA scan as the primary test for RUQ pain with elevated liver function tests—this is only appropriate for suspected acalculous cholecystitis or when ultrasound is equivocal for acute cholecystitis 2
• Do not skip ultrasound and go directly to CT or MRI, as this exposes you to unnecessary radiation or cost without diagnostic benefit 1, 2
• Do not delay imaging if you have fever, jaundice, or severe pain, as these suggest complications requiring urgent intervention 1
• Patients with ongoing signs of infection beyond 7 days of antibiotic treatment warrant repeat diagnostic investigation 1

When to Seek Emergency Care

You should go to the emergency department immediately if you have:

• Fever with RUQ pain (suggests acute cholecystitis or cholangitis) 1
• Jaundice (yellow skin/eyes suggesting biliary obstruction) 2, 3
• Severe, unrelenting pain 1
• Peritoneal signs (rigid abdomen, rebound tenderness suggesting perforation) 1