What is the recommended evaluation and management for a middle‑aged overweight woman with right‑upper‑quadrant pain radiating to the shoulder, nausea and possible gallbladder disease?

Evaluation and Management of Suspected Gallbladder Disease

Begin with right upper quadrant ultrasound as the initial imaging test, followed by laboratory evaluation including liver function tests, pancreatic enzymes, and complete blood count. 1, 2

Initial Diagnostic Workup

Laboratory Testing

• Obtain a comprehensive metabolic panel with liver function tests (AST, ALT, alkaline phosphatase, GGT, total/direct bilirubin) to assess for biliary obstruction or cholestasis 1
• Measure serum lipase or amylase to evaluate for concurrent pancreatitis 1
• Check complete blood count to detect leukocytosis suggesting acute cholecystitis 1
• Normal liver enzymes and pancreatic enzymes are required to meet Rome III criteria for functional gallbladder disorder 3

First-Line Imaging

• Right upper quadrant ultrasound is the initial imaging modality of choice, with 96% accuracy for detecting gallstones and ability to assess gallbladder wall thickening, pericholecystic fluid, and bile duct dilation 1, 2
• Ultrasound has high specificity (71-97%) for confirming or excluding mechanical biliary obstruction 1
• The sonographic Murphy sign (pain with probe pressure over the gallbladder) is specific for acute cholecystitis but has limited sensitivity, especially if the patient has received pain medication 1

Clinical Presentation Assessment

Typical Biliary Pain (Rome III Criteria)

Your patient's presentation should be evaluated against these specific criteria 3:

• Pain characteristics: Episodes lasting ≥30 minutes, occurring at different intervals (not daily), building to steady level, severe enough to interrupt activities
• Pain location: Right upper quadrant and/or epigastrium
• Radiation pattern: Pain radiating to the back and/or right infrascapular area (shoulder) is a supportive criterion 3
• Associated symptoms: Nausea and vomiting are supportive criteria 3
• Exclusion criteria: Pain not relieved by bowel movements, postural change, or antacids 3

The patient you describe—middle-aged, overweight woman with RUQ pain radiating to shoulder and nausea—fits the classic presentation for biliary disease 2, 4.

Advanced Imaging Based on Initial Results

If Ultrasound Shows Gallstones with Normal Bile Ducts

• Proceed to HIDA scan (cholecystokinin-cholescintigraphy) if symptoms are typical but ultrasound shows no acute cholecystitis, to evaluate for functional gallbladder disorder by measuring gallbladder ejection fraction 3, 2
• HIDA scan is appropriate when ultrasound findings are equivocal for acute cholecystitis 1, 2
• Do not order HIDA scan if symptoms are atypical, as abnormal gallbladder ejection fraction can occur in diabetes, celiac disease, irritable bowel syndrome, and with medications including opioids, calcium channel blockers, oral contraceptives, H2-blockers, and benzodiazepines 3

If Ultrasound Shows Dilated Bile Ducts or Elevated Liver Enzymes

• Order MRCP (magnetic resonance cholangiopancreatography) as the next imaging study, which has 85-100% sensitivity and 90% specificity for detecting choledocholithiasis and biliary obstruction 1
• MRCP provides superior visualization of the entire biliary tree compared to ultrasound or CT and is the preferred advanced imaging modality 1
• MRCP does not require IV contrast for detecting bile duct stones; the heavily T2-weighted sequences make bile appear bright and stones appear as dark filling defects 1

If Ultrasound is Negative but Suspicion Remains High

• Order MRCP to comprehensively evaluate the biliary tree for stones, strictures, or obstruction that may be missed on ultrasound 1
• Ultrasound has limited sensitivity (22.5-75%) for detecting common bile duct stones due to overlying bowel gas obscuring the distal CBD 1

Pain Management

Nonsteroidal anti-inflammatory drugs (NSAIDs) are safe and effective first-line therapy for biliary colic and acute cholecystitis pain. 2

• Opioids including morphine are appropriate for moderate-to-severe pain and do not interfere with diagnostic accuracy when combined with appropriate imaging 5
• Multimodal analgesia combining opioids with acetaminophen and NSAIDs reduces total opioid requirements 5
• The outdated concern that morphine causes sphincter of Oddi spasm and masks diagnosis is not supported by current evidence 5

Definitive Management

Symptomatic Gallstones or Acute Cholecystitis

• Refer for laparoscopic cholecystectomy, which is the treatment of choice 6, 2
• Surgery should be performed during the same hospitalization for acute cholecystitis, ideally within 72 hours of symptom onset 6

Functional Gallbladder Disorder (Acalculous Biliary Pain)

• If HIDA scan demonstrates abnormal gallbladder ejection fraction (<35%) in a patient meeting Rome III criteria, cholecystectomy is recommended based on expert consensus 3
• Ensure the patient has typical biliary pain and that other causes have been excluded with upper endoscopy at minimum 3

Choledocholithiasis (Common Bile Duct Stones)

• Perform ERCP with sphincterotomy and stone extraction when common bile duct stones are confirmed on MRCP 1
• Urgent ERCP (within 24 hours) is required if acute cholangitis is present (fever, jaundice, RUQ pain) 1, 6
• Early ERCP (within 72 hours) is indicated for biliary pancreatitis with ongoing obstruction 1, 6

Critical Pitfalls to Avoid

• Do not order CT scan as the initial imaging test—it has lower sensitivity (39-75%) for gallstones compared to ultrasound and exposes the patient to unnecessary radiation 1
• Do not perform HIDA scan in patients with atypical symptoms—this increases false positive rates and may lead to unnecessary cholecystectomy 3
• Do not dismiss normal early laboratory values—liver enzymes may be normal early in biliary obstruction 7
• Do not order ERCP as a diagnostic test—it should only be performed after non-invasive imaging confirms the need for therapeutic intervention, given risks of pancreatitis (3-5%), bleeding (2%), and cholangitis (1%) 1
• Do not assume dyspeptic symptoms (bloating, belching, food intolerance) are caused by gallstones—these symptoms are common in the general population and frequently persist after cholecystectomy 4

Risk Stratification

This patient's demographic profile (middle-aged, overweight, female) places her at increased risk for gallstone disease 2. The classic presentation of RUQ pain radiating to the shoulder with nausea strongly suggests biliary pathology rather than functional dyspepsia 3, 4. Approximately 80% of patients with gallstones remain asymptomatic, but once symptoms develop, there is a 6-10% annual risk of recurrent symptoms and 2% risk of complications 4.