J Clin Ultrasound 11:187-192, May 1983 Symposium Article

Acute Right Upper Quadrant Abdominal Pain: Ultrasound Approach

Howard Austin, MD

Acute right upper quadrant pain is a frequent presenting symptom in the general medical popu- lation. The expeditious proof of or exclusion of acute cholecystitis is a common diagnostic di- lemma. The differential diagnosis of right upper quadrant pain in Schwarz’ Textbook of Surgery (Table 1) is quite extensive with urgent surgery indicated in acute cholecystitis but not helpful or even contraindicated in the other conditions on that list. Even if acute cholecystitis seems the correct diagnosis clinically, the appropriate radiologic confirmatory test can be chosen from an almost equally long list. In this article, ul- trasound will be assessed as the primary tool in the work-up of acute right upper quadrant pain due to acute cholecystitis.

The sonographic sina-qua-non for gallbladder disease is cholelithiasis. Initial efforts focused upon the demonstration of gallstones using bi- stable, gray scale, and finally real-time ul- t r a ~ o u n d l - ~ with increased accuracy, up to 94.5% in Raptopoulos investigation.’ This latter study also demonstrated the relative speed and ease of real-time over articulated arm (Stark) ul- trasound. Crade et al.4 and Simeone et al.5 evolved subcategories which today offer accuracy of up to 100% in detecting gallstones. Category I is the “classic” gallstone: a clearly demonstrated gallbladder lumen containing a high amplitude echo (the gallstone) (Fig. 1) with distal “clean” acoustic shadowing and gravity dependance as the patient moves from supine to oblique to up- right positions (Fig. 2). This is virtually 100% diagnostic of cholelithiasis. Category I1 involves sonographic nonvisualization of the gallbladder lumen, despite fasting, often with high amplitude echoes in the gallbladder fossa with associated dis- tal acoustic shadowing. Crade et al. achieved a 96% accuracy rate, with Harbin et a1.6 close at

From t h e Department of Radiology, Division of CTI Ultrasound, Grady Memorial Hospital, Atlanta, Georgia. For reprints contact Howard Austin, MD, Assistant Professor, De- partment of Radiology, Division of CTiUltrasound, Grady Memorial Hospital, 69 Butler Street, SE, Atlanta, Georgia 30303.

0 1983 by John Wiley & Sons, Inc. 0091-27511831040187-06 $01 .OO

88% accuracy. Conrad et aL7 added confidence to diagnoses in this category (69 of 70 true positive) by adding the transverse left lateral decubitus view to the routine transverse and longitudinal views, to help exclude bowel gas as a factor in false-positive studies. Crade et al. felt that cate- gory I11 was more ambiguous, with an accuracy of only 61% if nonshadowing opacities were seen in the gallbladder lumen. Simeone et al. further subdivided category 111 into IIIA, in which there are nonshadowing echogenic foci Iess than 5 mm in size having an 81% incidence of gallstones at surgery and IIIB, in which a collection of non- shadowing diffuse low amplitude echoes forming a fluid-fluid level (“sludge”), unlikely to have gallstones at surgery (less than lo%), is seen (Figs. 3, 4).

Unfortunately, what the surgeons need to know urgently is which patients have acute cholecystitis, not chronic cholecystitis or cholelithiasis. That these groups are not inter- changeable is graphically demonstrated in the re- cent article from Gracie and Ransohoff’ in which 110 white male faculty members with inciden- tally discovered gallstones on oral cholecystog- raphy were found to have only an 18% chance of biliary pain up to 20 yr later. A distinction also needs to be made between acute and chronic cholecystitis, with their very different therapies and complications.

TABLE 1 Causes of Right Upper Quadrant Abdominal Pain

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Gallbladder and biliary tract Hepatitis Hepatic abscess Hepatomegaly due to congestive failure Peptic ulcer Pancreatitis Retrocecal appendicitis Renal pain Herpes Zoster Myocardial ischemia Pericarditis Pneumonia Empyema

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188 HOWARD AUSTIN

FIGURE 1. Longitudinal sonogram showing the ”classical“ gallstone (arrow). Note acoustic shadow (arrows) through right kidney (L = Liver).

FIGURE 2. Erect longitudinal view of gallbladder (G) , showing gravity dependence of the gallstone (arrow)

Gallbladder wall thickness has received con- siderable attention, with some general concur- rence over very broad ranges. Engel et al.’ com- pared 44 asymptomatic controls with 40 patients with surgically-measured gallbladder walls and pathologic proof of disease. Ninety-three percent of surgically measured gallbladder walls were within 1 mm of the sonographic measurement, establishing sonographic accuracy of measure- ments. The specificity of gallbladder wall thick- ness greater than 3.5 mm was 98% (Fig. 5); unfor- tunately the sensitivity was only 53%, with nearly half the diseased gallbladders falling in

the “normal” range for wall thickness. Not specifically noted in this article is that the “dis- eased” group included a mixture of acute and chronic, calculous and acalculous cholecystitis and cholesterolosis. Others1’-12 have made com- patible observations. Raghavendra et al.13 es- tablished 5 mm as the threshold for disease. Ex- ceptions are made for patients with hy- poalbuminemia, l4 asci tes, l1 heart failure, renal failure, multiple myeloma, and hepatitis, among others.13 Raghavendra’s group, with careful pathologic analysis, demonstrated the gallblad- der wall thickening and resultant anechoic halo

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RIGHT UPPER QUADRANT ABDOMINAL PAIN 189

FIGURE 3. A layer of surgically-proven fine calculi (arrows) or "gravel" is noted. Layering occurs with sub- stances of different specific gravities.

FIGURE 5. Sonogram demonstrates a markedly thickened (8 mm) gallbladder wall (small arrows), with a mixture of "sludge" (low am- plitude echoes) and calculi (higher amplitude echoes-large arrows) in gallbladder lumen.

FIGURE 4. A small gallstone (large arrows) is seen in a gravity- dependent position with associated acoustic shadowing. A layer of "sludge" (small arrows) is also present.

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190 HOWARD AUSTIN

FIGURE 6. An irregular sonolucent collection (A) is seen anterior to the more oval gallbladder lumen (GI which is itself echofree. Surgery revealed a pericholecystic abscess and ruptured gallbladder in a patient with acalculous cholecvstitis.

FIGURE 7. A transverse section through the lower edge of the liver (L) in a patient with ascites (a) demon- strates calculi (arrows) packed into the gallbladder with almost no residual lumen. A broad distal acoustic shadow is present. The ascites was a serendipitous finding.

to be edema in the perimuscular layer but this it calculous or a c a l c ~ l o u s , ~ ~ ~ ~ ~ include gallbladder finding has no correlation with the severity of the wall sonolucency (subserosal edema), peri- inflammatory process and is without predictive cholecystic abscess (Fig. 6) (with a range from value with regard to the clinically severe compli- anechoic to very ~omplex),'~,'~ or focal gallbladder cation of rupture of the inflamed gallbladder. tenderness (the sonographic Murphy sign), a

Other ancillary signs of acute cholecystitis, be rather subjective finding.g As Raghavendra et al.

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RIGHT UPPER QUADRANT ABDOMINAL PAIN 191

suggested and Madrazo confirmed, prospective diagnosis of gallbladder rupture was not possible; the latter article suggested serial ultrasound ex- aminations as a way to discover perforation as early as possible. Parulekarlg mentions gas in the gallbladder wall as a rare additional sign requir- ing an abdominal radiograph for confirmation.

In the end, is ultrasound alone sufficient in evaluating acute right upper quadrant abdominal pain? How does it compare to other imaging mo- dalities20’21 in the radiologic a r m a n t a r i ~ m , ~ ~ , ~ ~ such as oral cholecystography. Plain abdominal radiographs may be helpful, but the serious choice for most clinicians with an acutely ill pa- tient lies between ultrasound and ”“Tc-IDA analog cholescintigraphy. As Laing et al.’* and Shuman et al.25 point out, about one-third of pa- tients with acute right upper quadrant pain will have acute cholecystitis. Shuman, with a less pre- selected patient group than in Weissmann et al’s. landmark article on “HIDA” scanning,26 found sonography 96% accurate in detecting gallblad- der disease. In this series PIPIDA scintigraphy was 74% accurate in selecting from this group the patients with acute cholecystitis and separating normal patients from those with chronic cholecys- titis. He and Berkman,” among others, point out how technically easy, rapid, portable, and rela- tively less expensive sector real-time ultrasound scanning is, especially in bed-ridden patients with life-support systems in place.

So-called “serendipitous” findings occur with both sonography and ch~lescintigraphy.’~ The bias of this author favors ultrasound in this re- gard, but no study has been done (or possibly could be done) to prove this feeling. Ultrasound may be particularly efficacious in the jaundiced patient where the distinction between obstructive and nonobstructive jaundice needs to be made and where the cause of obstruction (if present) can often be seen.28

Probably closest to “truth” is the group from USC Medical Center’‘ who found both ultrasound and radionuclide study of the possibly diseased gallbladder to be virtually equally accurate (84.7% and 88.1%, respectively). More important, “there was no instance in which sonography and cholecyscintigraphy were congruently incorrect or equivocal.” Both tests can be performed promptly (in 1-2 hr or less under duress with cooperation between sections) leading to virtually 100% accu- racy.29 In this author’s 1000 bed acute-care inner- city hospital, this is in fact the practice. In an institution where both modalities are performed well technically, interpreted with skill and expe-

rience, and when the patient can tolerate both studies, there is no special order to the use of these modalities in the rapid work-up of acute right upper quadrant pain.

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Conrad MR, Leonard J , Landay MJ: Left lateral decubitus sonography of gallstones in the con- tracted gallbladder. A J R 134:141-144, 1980. Gracie WA, Ransohoff DF: The natural history of silent gallstones: The innocent gallstone is not a myth. N Engl J Med 307:798-800, 1982. Engel JM, Deitch EA, Sikkema: Gallbladder wall thickness: Sonographic accuracy and relation to disease. A J R 134:907-909, 1980. Finberg HJ, Birnholz JC: Ultrasound evaluation of the gallbladder wall. Radiology 133:693-698, 1979. Sanders RC: The significance of sonographic gallbladder wall thickening. J Clin Ultrasound

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