Right Upper Quadrant Pain

Variant: 1 Right upper quadrant pain. Unknown etiology. Initial Imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US abdomen	Usually Appropriate	O
CT abdomen with IV contrast	Usually Appropriate	☢☢☢
Radiography abdomen	May Be Appropriate (Disagreement)	☢☢
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
CT abdomen without IV contrast	May Be Appropriate	☢☢☢
Nuclear medicine scan gallbladder	Usually Not Appropriate	☢☢
CT abdomen without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 2 Right upper quadrant pain. Suspected biliary disease. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US abdomen	Usually Appropriate	O
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
Nuclear medicine scan gallbladder	May Be Appropriate	☢☢
CT abdomen with IV contrast	May Be Appropriate	☢☢☢
CT abdomen without IV contrast	May Be Appropriate	☢☢☢
CT abdomen without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 3 Right upper quadrant pain. No fever and no high white blood cell (WBC) count. Suspected biliary disease. Negative or equivocal ultrasound. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI abdomen without and with IV contrast with MRCP	Usually Appropriate	O
MRI abdomen without IV contrast with MRCP	Usually Appropriate	O
CT abdomen with IV contrast	Usually Appropriate	☢☢☢
Nuclear medicine scan gallbladder	May Be Appropriate	☢☢
CT abdomen without IV contrast	May Be Appropriate	☢☢☢
CT abdomen without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 4 Right upper quadrant pain. Fever, elevated WBC count. Suspected biliary disease. Negative or equivocal ultrasound. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI abdomen without and with IV contrast with MRCP	Usually Appropriate	O
Nuclear medicine scan gallbladder	Usually Appropriate	☢☢
CT abdomen with IV contrast	Usually Appropriate	☢☢☢
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
CT abdomen without IV contrast	May Be Appropriate	☢☢☢
CT abdomen without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 5 Right upper quadrant pain. Suspected acalculous cholecystitis. Negative or equivocal ultrasound. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
Nuclear medicine scan gallbladder	Usually Appropriate	☢☢
Image-guided cholecystostomy	May Be Appropriate	Varies
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
CT abdomen with IV contrast	May Be Appropriate	☢☢☢
CT abdomen without IV contrast	May Be Appropriate	☢☢☢
CT abdomen without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Panel Members

Summary of Literature Review

Introduction/Background

Initial Imaging Definition

Discussion of Procedures by Variant

Variant 1: Right upper quadrant pain. Unknown etiology. Initial Imaging.

Variant 1: Right upper quadrant pain. Unknown etiology. Initial Imaging.
A. CT Abdomen

Variant 1: Right upper quadrant pain. Unknown etiology. Initial Imaging.
B. MRI Abdomen with MRCP

Variant 1: Right upper quadrant pain. Unknown etiology. Initial Imaging.
C. Nuclear Medicine Scan Gallbladder

Variant 1: Right upper quadrant pain. Unknown etiology. Initial Imaging.
D. Radiography Abdomen

Variant 1: Right upper quadrant pain. Unknown etiology. Initial Imaging.
E. US Abdomen

Variant 2: Right upper quadrant pain. Suspected biliary disease. Initial imaging.

Variant 2: Right upper quadrant pain. Suspected biliary disease. Initial imaging.
A. CT Abdomen

Variant 2: Right upper quadrant pain. Suspected biliary disease. Initial imaging.
B. MRI Abdomen with MRCP

Variant 2: Right upper quadrant pain. Suspected biliary disease. Initial imaging.
C. Nuclear Medicine Scan Gallbladder

Variant 2: Right upper quadrant pain. Suspected biliary disease. Initial imaging.
D. US Abdomen

Variant 3: Right upper quadrant pain. No fever and no high white blood cell (WBC) count. Suspected biliary disease. Negative or equivocal ultrasound. Next imaging study.

Variant 3: Right upper quadrant pain. No fever and no high white blood cell (WBC) count. Suspected biliary disease. Negative or equivocal ultrasound. Next imaging study.
A. CT Abdomen

Variant 3: Right upper quadrant pain. No fever and no high white blood cell (WBC) count. Suspected biliary disease. Negative or equivocal ultrasound. Next imaging study.
B. MRI Abdomen with MRCP

Variant 4: Right upper quadrant pain. Fever, elevated WBC count. Suspected biliary disease. Negative or equivocal ultrasound. Next imaging study.

Variant 4: Right upper quadrant pain. Fever, elevated WBC count. Suspected biliary disease. Negative or equivocal ultrasound. Next imaging study.
A. CT Abdomen

Variant 4: Right upper quadrant pain. Fever, elevated WBC count. Suspected biliary disease. Negative or equivocal ultrasound. Next imaging study.
B. MRI Abdomen with MRCP

Variant 4: Right upper quadrant pain. Fever, elevated WBC count. Suspected biliary disease. Negative or equivocal ultrasound. Next imaging study.
C. Nuclear Medicine Scan Gallbladder

Variant 5: Right upper quadrant pain. Suspected acalculous cholecystitis. Negative or equivocal ultrasound. Next imaging study.

Variant 5: Right upper quadrant pain. Suspected acalculous cholecystitis. Negative or equivocal ultrasound. Next imaging study.
A. CT Abdomen

Variant 5: Right upper quadrant pain. Suspected acalculous cholecystitis. Negative or equivocal ultrasound. Next imaging study.
B. MRI Abdomen with MRCP

Variant 5: Right upper quadrant pain. Suspected acalculous cholecystitis. Negative or equivocal ultrasound. Next imaging study.
C. Nuclear Medicine Scan Gallbladder

Variant 5: Right upper quadrant pain. Suspected acalculous cholecystitis. Negative or equivocal ultrasound. Next imaging study.
D. Image-Guided Biopsy Liver

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination