Diagnostic Imaging for Right Upper Quadrant Pain with Jaundice

Initial Imaging Recommendations

The American College of Radiology recommends ultrasound abdomen as the initial imaging for patients with abnormal liver function tests showing hyperbilirubinemia or acute/subacute cholestasis 1, 2, 3, 4
The American College of Radiology and American Family Physician designate ultrasonography as the initial imaging test of choice for right upper quadrant pain 5, 6
The Infectious Diseases Society of America suggests abdominal ultrasound as the initial diagnostic imaging modality for suspected acute cholecystitis or acute cholangitis in nonpregnant adults 7

Ultrasound effectively detects biliary dilatation, gallstones, and evidence of biliary obstruction 5, 8, 9
Ultrasound can confirm or exclude mechanical obstruction with specificities ranging from 71% to 97% 9, 10

If ultrasound is equivocal or non-diagnostic, the American College of Radiology recommends either MRCP or CT abdomen with IV contrast as equivalent alternatives for further evaluation 1, 2, 3, 4
MRCP is superior to CT for evaluating the biliary system and determining the etiology of biliary obstruction, with MRI showing 90.7% accuracy versus CT's 85.1% for detecting biliary obstruction 1, 3, 4
CT abdomen with contrast can identify the site of obstruction and potential etiologies with high sensitivity (95%) and specificity (93.35%) for malignant biliary strictures 3

Order ultrasound abdomen as initial imaging, as recommended by the American Family Physician and the American College of Radiology 5, 1, 7, 6
If ultrasound identifies gallstones, biliary dilatation, or cholecystitis, proceed with appropriate management, as suggested by the American Family Physician and the Journal of the American College of Radiology 5, 8
If ultrasound is equivocal or shows biliary dilatation without clear etiology, order MRCP to evaluate for biliary obstruction etiology, as recommended by the American College of Radiology 1, 3, 4