Diagnostic Imaging Pathways - 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: 2017/2018
Published: December 2014
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| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | 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
pain
Chronic Right Upper Quadrant Pain
- Chronic Right Upper Quadrant pain can be caused by a wide variety of organic and functional causes including 1
- Cholelithiasis
- Peptic ulcer
- Pancreatitis
- Gastroesophageal reflux
- Tumours
- Functional disorders as detailed in the ROME III criteria pertaining to Functional Gallbladder and Sphincter of Oddi Disorders 2
ctc
Spiral Computed Tomography - Intravenous Cholangiography (CT-IVC)
- Spiral CT-IVC is a non-invasive technique that can be utilised to evaluate biliary anatomy and pathology 6
- It may be an alternative to MRCP, given cost and resource allocation issues with MRI techniques
- Cohort studies have validated Spiral CT-IVC when compared to invasive cholangiographic techniques (ERCP or intra-operative cholangiogram). The sensitivity and specificity in the detection of choledocholithiasis has been reported as 95% and 94-97% respectively 7,8
- A limitation of this modality arises in patients with abnormally high bilirubin levels. A level two to three times normal results in lower opacification of the biliary tree, resulting in difficulties detecting abnormal biliary anatomy and pathology 6,7
- Advantages: Readily available, non-invasive, high inter-observer correlation for pathology noted
- Limitations: Image degradation in patients with high bilirubin, poor or absent contrast excretion resulting in a low quality scan, need for intravenous contrast
ct
Computed Tomography
- Indications
- Cause of obstruction uncertain on US and there is high clinical suspicion of malignant obstruction 9
- For staging and surgical planning 10
- Compared to US, CT provides a more comprehensive examination that permits evaluation of the liver, biliary tree, pancreas, portal and retroperitoneal lymph nodes, and vascular structures 10
- For the diagnosis of pancreatic adenocarcinoma, spiral CT has a superior sensitivity of 91-97% compared to MRI (84%) and US (76%) 11,12
- 76-88% sensitivity and 98% specificity for common bile duct stones 13,14
- Limitations 13,14
- False negatives due to non-enlarged common bile ducts or small stones
- False positives due to pancreatic calcifications
- For more general consumer information on CT InsideRadiology
ultrasound
Ultrasound
- In patients with chronic right upper quadrant or biliary type pain Ultrasound (US) should be the initial imaging choice
- Where cholelithiasis is suspected US has good ability to detect this with a sensitivity of 0.84 and specificity of 0.99 3
- The sensitivity of US to detect ductal masses and mural thickening in hilar and extrahepatic cholangiocarcinoma ranges from 87 percent 4 to 96 percent 5
- For more general consumer information on ultrasound InsideRadiology
mrcp
Magnetic Resonance Cholangiopancreatography (MRCP)
- MRCP is more suitable for imaging the bile ducts compared to diagnostic ERCP if hilar obstruction is present on CT or ultrasound
- Non-invasive alternative to ERCP. 15-17 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
- High diagnostic accuracy (>94%) for the diagnosis of bile duct obstruction, choledocholithiasis, and malignant bile duct obstruction 18-20
- Advantages: non-invasive, no ionising radiation or contrast material and allows diagnosis and treatment planning in many patients without invasive cholangiography
- Limitations: low spatial resolution, does not offer therapeutic opportunity, availability and cost
disorders
Functional Disorders
- Functional Gallbladder and Sphincter of Oddi Disorders are a category of Functional Gastrointestinal Disorders (FGID). FGIDs are common and occur as a result of abnormal functioning of the gastrointestinal tract and are not caused by biochemical or structural abnormalities. As a result all investigations seeking to clarify symptoms experienced by patients with FGIDs are invariably normal
- Conditions in this spectrum include Functional Gallbladder Disorder, Functional Biliary Sphincter of Oddi Disorder and Functional Pancreatic Sphincter of Oddi Disorder
- For more information on the specific criterion that must be met to satisfy these conditions Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders
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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