From the Guidelines
The workup for right upper quadrant (RUQ) pain with fever should begin with a thorough history and physical examination, followed by laboratory tests including complete blood count, liver function tests, and inflammatory markers (CRP, ESR), and initial imaging should include an abdominal ultrasound to evaluate for common causes such as cholecystitis, cholelithiasis, or hepatic abscess. According to the American College of Radiology Appropriateness Criteria 1, ultrasound (US) is the first choice of investigation for biliary symptoms or right upper quadrant abdominal pain, with a reported accuracy of 96% for detection of gallstones.
Initial Evaluation
The initial evaluation should include:
- A thorough history and physical examination
- Laboratory tests including complete blood count, liver function tests, and inflammatory markers (CRP, ESR)
- Initial imaging with an abdominal ultrasound to evaluate for common causes such as cholecystitis, cholelithiasis, or hepatic abscess
Additional Testing
If ultrasound is inconclusive, additional tests may include:
- CT scan with contrast for better visualization of the liver, gallbladder, and surrounding structures
- HIDA scan for suspected biliary dyskinesia
- MRCP if biliary obstruction is suspected
- Blood cultures should be obtained if sepsis is a concern
Management
Empiric antibiotic therapy may be initiated with piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours if acute cholecystitis or cholangitis is suspected, pending culture results. Pain management with acetaminophen 1000mg every 6 hours and/or NSAIDs like ketorolac 30mg IV initially then 15-30mg every 6 hours is appropriate, as suggested by the American College of Radiology Appropriateness Criteria 1.
Complications
These symptoms warrant urgent evaluation as they often indicate serious conditions like acute cholecystitis, ascending cholangitis, or hepatic abscess, which can rapidly progress to sepsis if not promptly addressed. The use of Tc-99m cholescintigraphy, MRI abdomen with IV contrast with MRCP, or CT abdomen with IV contrast may be appropriate for further evaluation, as stated in the American College of Radiology Appropriateness Criteria 1.
From the Research
Evaluation Approach
The evaluation of a patient with right upper quadrant pain and temperature involves a combination of history, physical examination, laboratory testing, and diagnostic imaging 2. The differential diagnosis is broad and includes gastrointestinal and non-gastrointestinal causes for pain.
Diagnostic Imaging
- Ultrasound is recommended as the first-line imaging modality for the diagnosis of gallstones and cholecystitis, as it allows for the differentiation of medical and surgical causes of upper abdominal pathology 3.
- For patients presenting with a positive Murphy sign, sonography and biliary scintigraphy are the most useful initial imaging techniques 4.
- In patients with fever and a negative Murphy sign, a combination of sonography and contrast-enhanced CT can establish the diagnosis in most cases 4.
- CT and MR imaging also play important roles in evaluating patients with right upper quadrant pain, particularly in cases where ultrasonography is indeterminate 5.
Laboratory Testing and Physical Examination
- A physical examination, including the assessment of signs such as the Murphy sign, is essential in evaluating patients with right upper quadrant pain 2, 4.
- Laboratory testing, including blood work and other diagnostic tests, may also be necessary to establish a diagnosis and guide management 2.
Common Diagnoses
- Acute cholecystitis is a common cause of right upper quadrant pain and may be associated with complications that have characteristic imaging features 5.
- Other disorders of the liver, gallbladder, and biliary tree may also cause right upper quadrant pain, and imaging plays a key role in establishing a prompt diagnosis and guiding appropriate management 5.