In a patient with right upper quadrant pain and normal ultrasound, normal HIDA scan, normal CT abdomen, and normal pelvic exam who has not yet tried a proton‑pump inhibitor or dicyclomine, what is the next appropriate step in management?

Management of Right Upper Quadrant Pain with Negative Biliary Workup

Given that ultrasound, HIDA scan, and CT abdomen are all normal, the next step is to obtain MRI with MRCP to comprehensively evaluate the biliary tree for subtle pathology missed by prior imaging, and simultaneously initiate an empiric trial of a proton pump inhibitor to address potential gastroesophageal or gastroduodenal sources of pain. 1, 2, 3

Advanced Imaging: MRCP as the Definitive Next Step

Order MRI abdomen with MRCP (with IV gadolinium contrast) as your next imaging study. 2, 3

• MRCP achieves 85-100% sensitivity and 90% specificity for detecting choledocholithiasis and biliary obstruction that may be missed on ultrasound and CT 3
• MRCP excels at visualizing the gallbladder neck, cystic duct, and common bile duct stones that ultrasound cannot adequately assess 3
• MRCP can identify biliary strictures, sphincter of Oddi dysfunction, low-grade partial biliary obstruction, and intrahepatic biliary abnormalities that cause intermittent RUQ pain mimicking chronic cholecystitis 2, 3, 4
• The American College of Radiology explicitly recommends MRCP as superior to repeat CT for evaluating persistent RUQ pain when initial imaging is negative 1, 3

Why MRCP Over Repeat HIDA Scan

• Your patient already had a normal HIDA scan, which rules out acute cholecystitis and acalculous cholecystitis 2
• HIDA scan evaluates gallbladder function but does not visualize bile duct anatomy, strictures, or stones in the common bile duct 2, 3
• MRCP provides comprehensive anatomic visualization of the entire hepatobiliary system that HIDA cannot offer 2, 3

Empiric Medical Therapy: Start PPI Trial

Initiate a proton pump inhibitor (omeprazole 20-40 mg daily or equivalent) for 4-8 weeks as an empiric trial. 5, 6, 7

• RUQ pain can originate from gastroesophageal reflux disease, peptic ulcer disease, or gastroduodenal pathology that may not be evident on abdominal imaging 1
• PPIs provide potent acid suppression with high healing rates for acid-peptic diseases and are superior to H2-receptor antagonists 5
• PPIs are safe for short-term empiric trials with minimal adverse effects, making them appropriate for diagnostic and therapeutic purposes 7

Important Caveat About Dicyclomine

Do NOT start dicyclomine at this time. 8

• Dicyclomine (an anticholinergic) can worsen gastroesophageal reflux, particularly in the supine position, by increasing reflux episodes and prolonging acid clearance time 8
• Dicyclomine decreases peristaltic amplitude and may exacerbate symptoms if the pain has an upper GI origin 8
• Reserve dicyclomine only if functional biliary dyskinesia or sphincter of Oddi dysfunction is confirmed on further testing 2, 4

Specific Conditions to Evaluate with MRCP

MRCP will help identify these commonly missed diagnoses: 2, 3, 4

• Sphincter of Oddi dysfunction: Functional obstruction causing intermittent RUQ pain with normal standard imaging 2, 4
• Biliary dyskinesia: Low gallbladder ejection fraction causing chronic intermittent biliary-type pain without gallstones 4
• Choledocholithiasis: Small common bile duct stones missed on ultrasound (which has only 22.5-75% sensitivity for CBD stones) 3
• Biliary strictures: Post-inflammatory or idiopathic strictures causing partial obstruction 2
• Primary sclerosing cholangitis: Multifocal stricturing and dilatation of bile ducts 2

Additional Laboratory Studies to Order

Obtain comprehensive liver function tests if not already done: 4

• GGT, alkaline phosphatase, AST/ALT, total and direct bilirubin, complete blood count 4
• GGT elevates earlier and persists longer than alkaline phosphatase in cholestatic disorders, helping confirm hepatobiliary origin 4
• Elevated cholestatic enzymes with normal imaging strongly indicates the need for MRCP 3

Clinical Algorithm Summary

1. Order MRI abdomen with MRCP with IV gadolinium contrast 2, 3
2. Start PPI (omeprazole 20-40 mg daily) for 4-8 week trial 5, 6
3. Obtain liver function tests including GGT if not recently done 4
4. If MRCP shows biliary dyskinesia or sphincter of Oddi dysfunction, consider cholecystokinin-augmented cholescintigraphy with gallbladder ejection fraction calculation 2, 4
5. If MRCP and PPI trial are both negative/unhelpful, consider upper endoscopy to evaluate for gastroduodenal pathology 1

Critical Pitfalls to Avoid

• Do not dismiss this patient's pain as functional without completing advanced imaging 3, 4
• Do not order repeat ultrasound or CT—these modalities have already been exhausted and are inferior to MRCP for biliary tree evaluation 1, 3
• Do not proceed directly to ERCP without non-invasive imaging confirmation of pathology requiring intervention, as ERCP carries risks of pancreatitis and perforation 3
• Do not start dicyclomine empirically—it may worsen symptoms if the etiology is gastroesophageal 8