What is the appropriate workup and management for a patient with intermittent right‑upper‑quadrant and occasional left‑upper‑quadrant abdominal pain who denies nausea, vomiting, and diarrhea?

Workup and Management of Intermittent Right and Left Upper Quadrant Pain Without Nausea, Vomiting, or Diarrhea

Initial Imaging Recommendation

Order a right upper quadrant ultrasound immediately as the first-line diagnostic test. 1, 2, 3 This is the mandatory initial imaging modality rated 9/9 (usually appropriate) by the American College of Radiology for evaluating upper quadrant abdominal pain. 2, 3

Why Ultrasound First

• Ultrasound provides rapid, cost-effective evaluation without radiation exposure and can identify gallstones with 96% accuracy, assess gallbladder wall thickening (>3mm), detect pericholecystic fluid, evaluate bile duct dilatation, and identify alternative diagnoses across multiple organ systems. 1, 2, 4

• The absence of nausea, vomiting, and diarrhea does not exclude biliary pathology, as the "classic" presentation of acute cholecystitis occurs in only approximately 50% of patients. 5

• Ultrasound evaluates hepatic parenchyma, pancreas, kidneys, and vascular structures, allowing detection of non-biliary causes of upper quadrant pain including hepatic masses, renal pathology, and pancreatic abnormalities. 4

Laboratory Evaluation

Obtain a complete metabolic panel with liver function tests including transaminases (AST, ALT), alkaline phosphatase, GGT, total and direct bilirubin, and complete blood count with differential. 6

• Elevated alkaline phosphatase and bilirubin suggest biliary obstruction or cholestasis, requiring anatomic visualization of the bile ducts with advanced imaging. 6

• Normal laboratory values do not exclude significant pathology, particularly in elderly patients where typical signs of infection may be masked. 5

Clinical Algorithm Based on Ultrasound Findings

If Ultrasound Shows Gallstones or Biliary Abnormalities

• Proceed to surgical consultation if ultrasound demonstrates ≥2 findings of acute cholecystitis (gallbladder wall thickening, pericholecystic fluid, sonographic Murphy's sign, gallbladder distension, or stones/sludge). 1

• Order MRCP (MR cholangiopancreatography) if bile duct dilatation or elevated liver enzymes are present, as MRCP achieves 85-100% sensitivity and 90% specificity for detecting choledocholithiasis and biliary obstruction. 6

If Ultrasound is Normal or Equivocal

• Consider functional gallbladder disease and order a HIDA scan with cholecystokinin stimulation to calculate gallbladder ejection fraction. 7, 3

• Biliary dyskinesia (ejection fraction <35%) or biliary hyperkinesia (ejection fraction >80%) can cause intermittent biliary colic despite normal ultrasound findings. 7, 8

• Initiate an empiric trial of a proton pump inhibitor (omeprazole 20-40 mg daily for 4-8 weeks) to address possible gastroesophageal reflux disease or peptic ulcer disease as alternative causes of upper quadrant pain. 6

If Both Ultrasound and HIDA Scan are Unrevealing

• Order MRI abdomen with MRCP and IV gadolinium contrast to comprehensively evaluate the liver parenchyma, biliary tree, pancreas, and detect subtle abnormalities not visible on ultrasound or CT. 6

• Proceed to upper endoscopy if MRCP and PPI trial fail to identify a cause, to directly evaluate for gastroduodenal pathology such as erosive esophagitis or ulcer disease. 6

When to Escalate to CT

Reserve CT abdomen/pelvis with IV contrast for specific scenarios:

• Critically ill patients with peritoneal signs suggesting complications such as gallbladder perforation, emphysematous cholecystitis, or abscess formation. 2, 6

• Atypical presentations where the differential diagnosis extends beyond biliary disease to include bowel obstruction, mesenteric ischemia, or other acute abdominal pathology. 5

• Ultrasound findings that are nondiagnostic or equivocal and require comprehensive evaluation. 2

Critical Pitfalls to Avoid

• Do not skip ultrasound and proceed directly to CT, as ultrasound is the appropriate first-line test and CT has only 75% sensitivity for gallstones compared to ultrasound's 96% accuracy. 2

• Do not assume normal imaging excludes functional gallbladder disorders, as biliary dyskinesia and hyperkinesia cause real symptoms despite normal morphology. 7, 8

• Do not order CT without IV contrast if biliary pathology is suspected, as critical findings like gallbladder wall enhancement and adjacent liver parenchymal hyperemia cannot be detected without contrast. 2

• Do not dismiss intermittent pain as benign without completing the diagnostic algorithm, as up to 80% of gallstones are noncalcified and may be missed on CT, and functional disorders require specific testing. 6

Alternative Diagnoses to Consider

The differential diagnosis for upper quadrant pain extends beyond biliary disease:

• Gastroesophageal and gastroduodenal pathology including GERD, peptic ulcer disease, and gastritis can present with upper quadrant pain. 6, 4

• Hepatic causes including fatty liver disease, cirrhosis, hepatic masses, or hepatic congestion. 6, 4

• Pancreatic pathology including chronic pancreatitis or pancreatic masses. 4

• Renal causes including nephrolithiasis or pyelonephritis can refer pain to the upper quadrants. 4

• Musculoskeletal and thoracic causes including costochondritis, rib fractures, or lower lobe pneumonia. 4