Diagnostic Approach for Right Upper Quadrant Pain with Jaundice

Initial Evaluation

The American College of Radiology recommends abdominal ultrasound as the first-line imaging modality for evaluating right upper quadrant pain with suspected biliary disease and jaundice, due to its high specificity and sensitivity for detecting biliary obstruction and gallstones 1, 2
Ultrasound has 96% accuracy for detecting gallstones, which are the most common cause of obstructive jaundice, and can simultaneously assess for gallbladder wall thickening, pericholecystic fluid, and intrahepatic/extrahepatic bile duct dilatation 1, 2

If ultrasound demonstrates biliary dilatation or is equivocal, MRCP should be the next step, as it has 85-100% sensitivity and 90% specificity for detecting choledocholithiasis and biliary obstruction 3
MRCP can identify the level and cause of biliary obstruction with 91-100% accuracy, including stones, strictures, masses, and lymph nodes 3

The American College of Radiology explicitly recommends ultrasound first, followed by advanced imaging based on ultrasound findings, to provide a cost-effective, stepwise approach 1, 2, 3
CT is less sensitive than ultrasound for initial biliary evaluation and exposes patients to radiation without clear advantage as a first-line test 3, 4