Diagnostic Approach to Right Upper Quadrant Pain

History Components

The American Academy of Family Physicians recommends assessing pain characteristics, including onset, duration, quality, severity, radiation, and exacerbating/alleviating factors, as biliary colic typically presents as episodic, severe pain that may radiate to the right shoulder or back 1
The American College of Radiology suggests documenting associated symptoms, such as fever, nausea, vomiting, anorexia, jaundice, changes in bowel habits, or weight loss 2, 3
The European Association for the Study of the Liver recommends recording all medications taken within 6 weeks of presentation, including prescription drugs, over-the-counter medications, herbal medicines, and supplements 4
A thorough medical history should note any history of biliary disease, prior biliary surgery, liver disease, or other relevant conditions, as suggested by the American Association for the Study of Liver Diseases 4
Inquiring about family history of cholestatic liver disease or other hereditary disorders that may cause RUQ pain is also recommended by the European Association for the Study of the Liver 4
The American College of Gastroenterology suggests documenting alcohol intake, as alcoholic liver disease can present with RUQ pain 4

The American College of Radiology recommends checking for fever, tachycardia, or hypotension, which may indicate infection or sepsis 2
Assessing for right upper quadrant tenderness is suggested by the American Academy of Family Physicians and the American College of Radiology 1, 2
Murphy's sign, which is pain with inspiration during palpation of the right upper quadrant, is highly suggestive of acute cholecystitis, as noted by the American College of Radiology 2, 3
The American Association for the Study of Liver Diseases recommends examining for hepatomegaly or splenomegaly 4
Abdominal distension, masses, or peritoneal signs should also be assessed, as suggested by the American Academy of Family Physicians 1

The American College of Radiology recommends a complete blood count to assess for leukocytosis, which may indicate infection or inflammation 2
Liver function tests, including ALT, AST, alkaline phosphatase, GGT, and bilirubin, should be evaluated to assess for hepatobiliary disease, as suggested by the European Association for the Study of the Liver 4
The American Academy of Family Physicians recommends testing for pancreatic enzymes, such as amylase and lipase, to rule out pancreatitis 1
A pregnancy test should be performed for all women of reproductive age to rule out ectopic pregnancy or other pregnancy-related conditions, as recommended by the American College of Obstetricians and Gynecologists 5

The American Academy of Family Physicians and the American College of Radiology recommend ultrasonography of the abdomen as the first-line imaging modality for RUQ pain, with a high accuracy for diagnosing gallstones (96%) 1, 2, 6
Ultrasonography can identify gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy sign, as noted by the American College of Radiology 2, 3
If ultrasonography is inconclusive or additional imaging is needed, cholescintigraphy, CT with contrast, or MRI/MRCP may be considered, as suggested by the American College of Radiology and the American Academy of Family Physicians 6