What is the workup and management for an adult patient, especially over 50, with epigastric pain, right upper quadrant pain, and bloating?

Workup and Management of Epigastric and Right Upper Quadrant Pain with Bloating

Begin with abdominal ultrasound as your first-line imaging study—it is the single most appropriate initial test for evaluating both epigastric and right upper quadrant pain, with 96% accuracy for detecting gallstones and the ability to identify alternative diagnoses without radiation exposure. 1, 2

Initial Clinical Assessment

Key Historical Features to Elicit:

• Pain characteristics: Constant versus episodic, severity, radiation to back or right shoulder, nocturnal occurrence, and duration (biliary colic typically lasts hours) 3, 4
• Alarm symptoms requiring urgent evaluation: Fever, jaundice, hematemesis, dysphagia, unintentional weight loss, or age >50 with new-onset symptoms 1
• Associated symptoms: Nausea, vomiting, early satiety, heartburn, or regurgitation to differentiate between biliary disease, peptic ulcer disease, GERD, and functional dyspepsia 1, 5
• NSAID use: Chronic NSAID users require endoscopy regardless of other factors 1
• Prior cholecystectomy: Does not exclude choledocholithiasis, which presents with similar pain patterns 4

Essential Laboratory Workup

Order these tests for all patients:

• Complete blood count to assess for leukocytosis suggesting cholecystitis or infection 6
• Comprehensive metabolic panel including liver enzymes (ALT, AST, alkaline phosphatase, bilirubin) to evaluate for biliary obstruction or hepatobiliary disease 6, 4
• Amylase and lipase to rule out pancreatitis 6
• Pregnancy test for all women of reproductive age before any imaging 2, 6

Key laboratory patterns:

• Transaminase elevation is the most common abnormality in choledocholithiasis 4
• Cholestatic pattern (elevated alkaline phosphatase and bilirubin) suggests biliary obstruction 6

Imaging Algorithm

First-Line Imaging: Abdominal Ultrasound

Ultrasound is rated 9/9 (usually appropriate) by the American College of Radiology for both epigastric pain and right upper quadrant pain. 1, 2, 7

Ultrasound advantages:

• 96% accuracy for gallstone detection 1
• Evaluates gallbladder wall thickening, pericholecystic fluid, bile duct dilatation, and sonographic Murphy sign 1
• Identifies alternative diagnoses including hepatic, renal, and gynecologic pathology 7
• No radiation exposure, rapid, and cost-effective 2, 7

Critical pitfall: The sonographic Murphy sign has relatively low specificity and is unreliable if the patient received pain medication prior to imaging 1

Second-Line Imaging Options

If ultrasound is equivocal or complications are suspected:

• Cholescintigraphy (HIDA scan): 97% sensitivity and 90% specificity for acute cholecystitis, superior to ultrasound but reserved for equivocal cases 1, 2
• CT abdomen and pelvis with IV contrast: Use when complications (perforation, abscess, gangrenous cholecystitis) are suspected or alternative diagnoses need evaluation 1, 7
  • Never order CT without IV contrast for suspected cholecystitis—critical findings like gallbladder wall enhancement cannot be detected without contrast 7
  • CT has only 75% sensitivity for gallstones, so negative CT does not exclude cholelithiasis 7
• MRI with MRCP: 85-100% sensitivity for choledocholithiasis when bile duct pathology is suspected but ultrasound is equivocal 7

Management Based on Clinical Presentation

If Biliary Disease is Confirmed or Highly Suspected

Urgent surgical referral if:

• Fever with leukocytosis suggesting acute cholecystitis 7
• Charcot's triad (jaundice, fever/chills, RUQ pain) suggesting acute cholangitis 7
• Imaging shows complications (perforation, abscess) 7

Do not delay surgical consultation while awaiting additional imaging if clinical diagnosis of acute cholecystitis is established 7

If No Biliary Disease and Symptoms Persist >4 Weeks

For patients without alarm symptoms:

• Test for H. pylori infection and treat if positive using an appropriate test (urea breath test or stool antigen) 1
• This strategy is cost-effective and eliminates peptic ulcer mortality risk, though many patients will have residual functional dyspepsia symptoms after eradication 1

For H. pylori-negative patients or those with residual symptoms after eradication:

• If epigastric pain (ulcer-like dyspepsia) predominates: Full-dose PPI therapy (omeprazole 20 mg once daily) is first-line treatment 1
• If fullness, bloating, or early satiety (dysmotility-like dyspepsia) predominates: Consider prokinetic agents, though cisapride is contraindicated due to cardiac toxicity 1
• If no response to initial therapy: Switch treatment class (PPI to prokinetic or vice versa) or consider high-dose PPI trial 1

If Symptoms Persist Despite Medical Management

Refer for upper endoscopy when:

• Age >50 with new-onset symptoms (age cutoff depends on local gastric cancer incidence) 1
• Alarm symptoms present (dysphagia, hematemesis, weight loss) 1
• No response to empirical therapy after switching treatment classes 1
• Chronic NSAID use 1

Upper endoscopy with biopsy is the reference standard for diagnosing:

• Gastric cancer, which may present with nonspecific epigastric pain and bloating 1
• Peptic ulcer disease, esophagitis, and gastritis 1

Common Pitfalls to Avoid

• Failing to obtain pregnancy test before imaging in reproductive-age women—can lead to unnecessary radiation exposure and missed ectopic pregnancy 2, 6
• Ordering CT as first-line imaging—ultrasound is superior for initial evaluation and avoids radiation 2, 7
• Assuming gallbladder sludge alone equals cholecystitis—critically ill patients commonly have sludge without true acute cholecystitis 7
• Relying on negative CT to exclude gallstones—CT has only 75% sensitivity; ultrasound is the appropriate test 7
• Ignoring that ultrasound has only 88% sensitivity for acute cholecystitis—if clinical suspicion is high despite negative ultrasound, proceed to HIDA scan or CT 7

Special Considerations for Age >50

Gastric cancer risk increases with age, making endoscopy more important in older patients with new-onset symptoms, particularly those with weight loss or other alarm features 1

CT with IV contrast and neutral oral contrast (water or dilute barium) should be performed when gastric malignancy is suspected to assess for nodular wall thickening, soft tissue attenuation, lymphadenopathy, and distant metastases 1