A 42-year-old female presents to the emergency department with a 6-hour history of severe right upper quadrant abdominal pain that radiates to her right scapula. The pain started 30 minutes after eating a large, fatty meal. She also reports nausea and two episodes of vomiting. Her temperature is 38.2°C (100.8°F), blood pressure is 130/80 mmHg, pulse is 98/min, and respirations are 16/min. Physical examination reveals focal tenderness to palpation in the right upper quadrant with sudden inspiratory arrest upon deep palpation. Laboratory studies show a leukocyte count of 14,000/mm³ and normal liver function tests. Which of the following is the most appropriate next step in imaging for this patient?
- AComputed tomography (CT) scan of the abdomen and pelvis with intravenous contrast
- BHepatobiliary iminodiacetic acid (HIDA) scan
- CMagnetic resonance cholangiopancreatography (MRCP)
- Right upper quadrant abdominal ultrasoundAnswer
- EUpright plain abdominal radiograph
Answer
Right upper quadrant abdominal ultrasound
The patient's clinical presentation of postprandial right upper quadrant pain, fever, leukocytosis, and a positive Murphy sign is classic for acute cholecystitis. The most appropriate initial imaging study for suspected acute cholecystitis is a right upper quadrant abdominal ultrasound. It is highly sensitive for detecting gallstones, gallbladder wall thickening (>3 mm), and pericholecystic fluid, while remaining cost-effective and avoiding ionizing radiation.
Step-by-Step Solution
Key Concept
Right upper quadrant abdominal ultrasound is the preferred and most cost-effective initial imaging modality for patients presenting with signs and symptoms of acute cholecystitis.