• Bree RL, Rosen MP, Foley WD, Gay SB, Grant TH, Heiken JP, Huprich JE, Lalani T, Miller FH, Ros PR, Sudakoff GS, Greene FL, Rockey DC, Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria® right upper quadrant pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2007. 5 p. [16 references]

This is the current release of the guideline.

This guideline updates a previous version: Bree RL, Foley WD, Gay SB, Glick SN, Heiken JP, Huprich JE, Levine MS, Ros PR, Rosen MP, Shuman WP, Greene FL, Rockey DC, Expert Panel on Gastrointestinal Imaging. Right upper quadrant pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 5 p. [16 references]

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

ACR Appropriateness Criteria®

Clinical Condition: Right Upper Quadrant Pain

Variant 1: Fever, elevated WBC, positive Murphy sign.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 2: Suspected acalculous cholecystitis.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 3: No fever, normal WBC.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 4: No fever, normal WBC, ultrasound shows only gallstones.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 5: Hospitalized patient with fever, elevated WBC, and positive Murphy sign.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Summary of Literature Review

Acute right upper quadrant pain is a very common presenting symptom in patients presenting to hospital emergency rooms and in the occasional patient hospitalized for chronic disease or trauma. The primary diagnosis to be established in these patients is acute cholecystitis (AC) and the primary mode of treatment is laparoscopic cholecystectomy. It has been suggested empirically and by scientific evidence that approximately one-third of patients with presumptive diagnosis of AC will not be confirmed as AC on follow-up. Of patients who have surgery for AC, 20% to 25% may have a different diagnosis. These studies, of course, were primarily performed in the era before modern imaging. Additionally, because there are data indicating that surgery in AC leads to better outcomes, there is preference among surgeons to make a diagnosis based on the presence of gallstones and clinical findings and to perform early laparoscopic cholecystectomy. In fact, it might be necessary to redefine the patient outcomes of AC rather than rely on strict histologic criteria when, in the early stages of the disease, the histologic abnormalities may be minimal. In the otherwise healthy patient, imaging intervention may be only minimally necessary, but in more complicated patients a more complex protocol might be appropriate.

The evidence-based diagnosis of AC was studied in a meta-analysis published in 2003. No clinical or laboratory finding had a high or low enough likelihood ratio to predict its presence or absence. This study further supports the evidence that imaging studies are essential for the diagnosis. Much of the literature defining the role of imaging studies in evaluating patients with acute right upper quadrant pain is from the 1980s. When ultrasound (US) began to be used for these patients, it became obvious that it was destined to replace intravenous cholangiography and oral cholecystography for gallbladder evaluation. An initial study in 1981 defined the sonographic Murphy sign as focal gallbladder tenderness, which, along with sludge and gallbladder thickening, enabled physicians to separate acute from chronic cholecystitis in patients who harbored stones. Unfortunately, the sonographic Murphy sign does have a low specificity for AC.

In 1982, a study of the accuracy of scintigraphy with hepato-iminodiacetic acid (HIDA) compared with sonography indicated similar excellent results in 91 patients suspected of having AC. The overall accuracy of US was 88%, and for scintigraphy, it was 85%.

A study of 194 patients published in 1983 using strict criteria for pathologic diagnosis of AC and liberal criteria for US diagnosis (presence of stones) showed that, when scintigraphy was compared with US, sensitivities were high for both but specificity of US dropped to 64% with a positive predictive value of only 40%. The sonographic Murphy sign was not analyzed, nor was there correlation with clinical data.

Since these studies, other scattered articles in the radiologic literature have debated the role of US and scintigraphy in the diagnosis of AC. One criticism of scintigraphy is the time to perform the study (up to 4 hours to separate acute from chronic cholecystitis). The time can be diminished with the use of intravenous (IV) morphine, but the yield in otherwise healthy patients may not be significant because they will have the same outcome, a laparoscopic cholecystectomy. Some may argue that AC should be defined by the relief of symptoms following cholecystectomy. Authors often recommend US or scintigraphy, or both, for diagnosing AC; however, it is accepted that scintigraphy continues to have higher sensitivity and specificity than US. The role of scintigraphy remains for the individual surgeon or emergency physician to determine in an individual case.

Complications of AC include gangrene, empyema, and perforation. The sonographic Murphy sign may be absent when gangrenous AC is present, and other features such as pericholecystic fluid, gallbladder wall thickening, and dilated gallbladder are important in this group of patients.

With the routine use of laparoscopic cholecystectomy, the importance of preoperative or intraoperative detection of nonobstructing, asymptomatic common duct stones remains controversial. Common duct stones are present in 10% to 20% of patients with AC. One approach to predicting common duct stones uses the size of the gallstones present, with patients having multiple stones less than 5 mm in diameter more likely to have common duct stones than those with multiple larger stones or single large stones. In patients at higher risk for common duct stones, preoperative study with endoscopic retrograde cholangiopancreatography (ERCP) may be warranted.

The patient with acalculous cholecystitis is more problematic. The use of sonography and scintigraphy has been advocated, including using cholecystokinin to attempt to evaluate gallbladder contraction. The absence of stones, particularly in the patient presenting to the emergency room, should be confirmed with a follow-up examination if symptoms persist. Otherwise, acalculous cholecystitis seen in hospitalized patients as well as in a small percentage of patients presenting to the emergency room may be a diagnosis of exclusion. Computed tomography (CT) has a role in evaluating these critically ill patients. In the patient in the intensive care units, several centers perform percutaneous cholecystostomies. Others are less aggressive, or cholecystostomies are performed surgically.

Other clinical conditions that can simulate AC and present with acute right upper quadrant pain include chronic cholecystitis, peptic ulcer, pancreatitis, gastroenteritis, bowel obstruction, and many others. In this group of patients, CT and barium studies of the upper and lower gastrointestinal tract can be useful to identify alternative diagnoses.

In summary, the diagnosis of AC can often be made clinically with confirmation of gallstones necessary to confirm the need for laparoscopic cholecystectomy. A study has yet to be performed that relates cholecystectomy performed with this scenario to patient outcomes. Scintigraphy costs more, takes longer, and gives higher sensitivity and specificity than ultrasound, but it cannot contribute to a diagnosis if the etiology is not within the biliary tract. False positives can occur in patients with high bilirubin levels and severe intercurrent illnesses. False negatives are rare in AC. These guidelines should allow the radiologist, emergency physician, and surgeon to be comfortable in choosing an expedient modality or combination of modalities to make this important diagnosis.

Abbreviations

• CT, computed tomography
• ERCP, endoscopic retrograde cholangiopancreatography
• GI, gastrointestinal
• ICU, intensive care unit
• INV, invasive
• IP, in process
• Med, medium
• NUC, nuclear medicine
• US, ultrasound
• WBC, white blood cell

None provided

The recommendations are based on analysis of the current literature and expert panel consensus.

• Bree RL, Rosen MP, Foley WD, Gay SB, Grant TH, Heiken JP, Huprich JE, Lalani T, Miller FH, Ros PR, Sudakoff GS, Greene FL, Rockey DC, Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria® right upper quadrant pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2007. 5 p. [16 references]

Not applicable: The guideline was not adapted from another source.

1996 (revised 2007)

American College of Radiology - Medical Specialty Society

The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Committee on Appropriateness Criteria, Expert Panel on Gastrointestinal Imaging

Panel Members: Robert L. Bree, MD, MHSA; Max Paul Rosen, MD, MPH; W. Dennis Foley, MD; Spencer B. Gay, MD; Thomas H. Grant, DO; Jay P. Heiken, MD; James E. Huprich, MD; Tasneem Lalani, MD; Frank H. Miller, MD; Pablo R. Ros, MD, MPH; Gary S. Sudakoff, MD; Frederick L. Greene, MD; Don C. Rockey, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Bree RL, Foley WD, Gay SB, Glick SN, Heiken JP, Huprich JE, Levine MS, Ros PR, Rosen MP, Shuman WP, Greene FL, Rockey DC, Expert Panel on Gastrointestinal Imaging. Right upper quadrant pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 5 p. [16 references]

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

None available

This summary was completed by ECRI on March 19, 2001. The information was verified by the guideline developer on March 29, 2001. This summary was updated by ECRI on March 28, 2006. This summary was updated by ECRI Institute on June 24, 2009.