Upper Quadrant Pain (Chronic Right)
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Population Covered By The Guidance
This pathway provides guidance on imaging in adult patients with non-acute right upper quadrant abdominal pain in whom a biliary cause is suspected.
Date reviewed: September 2014
Date of next review: August 2023
Published: December 2014
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Teaching Points
Teaching Points
- Ultrasound is the initial imaging modality of choice in the assessment of Chronic Right Upper Quadrant pain
- The presence of bile duct dilatation on initial imaging, abnormal liver function tests or a history of jaundice will usually require further imaging
- Where a cause for bile duct dilatation, such as a mass, is suspected on initial imaging CT is recommended for better delineation of the cause
- Where no cause for bile duct dilatation is detected and serum bilirubin is greater than or equal to two times the normal limit or the patient is young then Magnetic Resonance Cholangiopancreatography (MRCP) is recommended
- CT Cholangiography is indicated where no cause for bile duct dilatation is seen and serum bilirubin levels are normal or near normal/ the patient is older. The use of CT Cholangiography in patients with high bilirubin levels can result in sub optimal imaging making it difficult to characterise biliary anatomy and the causative aetiology for bile duct dilatation
- Most authorities agree that ERCP should be largely reserved for therapeutic interventions (such as sphincterotomy, extraction of stones from the bile duct or stenting) after the diagnosis has been established by non-invasive imaging such as CT Cholangiogram or MRCP
References
References
Date of literature search: September 2014
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Othman SA. Right upper quadrant pain with normal hepatobiliary ultrasound: can hepatobiliary scintigraphy define the cause? Saudi J Gastroenterol. 2012;18(4):248-51. (Level III evidence). View the reference
- Drossman DA. The functional gastrointestinal disorders and the Rome III process. Gastroenterology. 2006;130(5):1377-90. (Review article). View the reference
- Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994;154(22):2573-81. (Level I evidence). View the reference
- Hann LE, Greatrex KV, Bach AM, Fong Y, Blumgart LH. Cholangiocarcinoma at the hepatic hilus: sonographic findings. AJR Am J Roentgenol. 1997;168(4):985-9. (Level II evidence). View the reference
- Robledo R, Muro A, Prieto ML. Extrahepatic bile duct carcinoma: US characteristics and accuracy in demonstration of tumors. Radiology. 1996;198(3):869-73. (Level III evidence). View the reference
- Alibrahim E, Gibson RN, Vincent J, Speer T, Collier N, Jardine C. Spiral computed tomography-intravenous cholangiography with three-dimensional reconstructions for imaging the biliary tree. Australas Radiol. 2006;50(2):136-42. (Level II evidence). View the reference
- Gibson RN, Vincent JM, Speer T, Collier NA, Noack K. Accuracy of computed tomographic intravenous cholangiography (CT-IVC) with iotroxate in the detection of choledocholithiasis. Eur Radiol. 2005;15(8):1634-42. (Level II evidence). View the reference
- Cabada Giadas T, Sarria Octavio de Toledo L, Martinez-Berganza Asensio MT, Cozcolluela Cabrejas R, Alberdi Ibanez I, Alvarez Lopez A, et al. Helical CT cholangiography in the evaluation of the biliary tract: application to the diagnosis of choledocholithiasis. Abdom Imaging. 2002;27(1):61-70. (Level II evidence). View the reference
- Baron RL, Stanley RJ, Lee JK, Koehler RE, Melson GL, Balfe DM, et al. A prospective comparison of the evaluation of biliary obstruction using computed tomography and ultrasonography. Radiology. 1982;145(1):91-8. (Level II/III evidence). View the reference
- Gulliver DJ, Baker ME, Cheng CA, Meyers WC, Pappas TN. Malignant biliary obstruction: efficacy of thin-section dynamic CT in determining resectability. AJR Am J Roentgenol. 1992;159(3):503-7. (Level III evidence). View the reference
- Bipat S, Phoa SS, van Delden OM, Bossuyt PM, Gouma DJ, Lameris JS, et al. Ultrasonography, computed tomography and magnetic resonance imaging for diagnosis and determining resectability of pancreatic adenocarcinoma: a meta-analysis. J Comput Assist Tomogr. 2005;29(4):438-45. (Level I-II evidence). View the reference
- Diehl SJ, Lehmann KJ, Sadick M, Lachmann R, Georgi M. Pancreatic cancer: value of dual-phase helical CT in assessing resectability. Radiology. 1998;206(2):373-8. (Level III evidence). View the reference
- Amouyal P, Amouyal G, Levy P, Tuzet S, Palazzo L, Vilgrain V, et al. Diagnosis of choledocholithiasis by endoscopic ultrasonography. Gastroenterology. 1994;106(4):1062-7. (Level II/III evidence).View the reference
- Neitlich JD, Topazian M, Smith RC, Gupta A, Burrell MI, Rosenfield AT. Detection of choledocholithiasis: comparison of unenhanced helical CT and endoscopic retrograde cholangiopancreatography. Radiology. 1997;203(3):753-7. (Level III evidence). (Level I evidence). View the reference
- Varghese JC, Farrell MA, Courtney G, Osborne H, Murray FE, Lee MJ. Role of MR cholangiopancreatography in patients with failed or inadequate ERCP. AJR Am J Roentgenol. 1999;173(6):1527-33. (Level II/III evidence). View the reference
- Fulcher AS, Turner MA, Capps GW, Zfass AM, Baker KM. Half-Fourier RARE MR cholangiopancreatography: experience in 300 subjects. Radiology. 1998;207(1):21-32. (Level II/III evidence). View the reference
- Soto JA, Yucel EK, Barish MA, Chuttani R, Ferrucci JT. MR cholangiopancreatography after unsuccessful or incomplete ERCP. Radiology. 1996;199(1):91-8. (Level II evidence). View the reference
- Guibaud L, Bret PM, Reinhold C, Atri M, Barkun AN. Bile duct obstruction and choledocholithiasis: diagnosis with MR cholangiography. Radiology. 1995;197(1):109-15. (Level II/III evidence). View the reference
- Becker CD, Grossholz M, Becker M, Mentha G, de Peyer R, Terrier F. Choledocholithiasis and bile duct stenosis: diagnostic accuracy of MR cholangiopancreatography. Radiology. 1997;205(2):523-30. (Level III evidence).View the reference
- Soto JA, Barish MA, Yucel EK, Siegenberg D, Ferrucci JT, Chuttani R. Magnetic resonance cholangiography: comparison with endoscopic retrograde cholangiopancreatography. Gastroenterology. 1996;110(2):589-97. (Level II evidence). View the reference
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