Right Upper Quadrant PainAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

449 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Abdominal Distension Abdominal Pain, Undifferentiated Acute Abdominal Pain (general)Suspected Incarcerated Or Strangulated Hernia Pancreatitis Concern Biliary Colic And Cholecystitis Concern Appendicitis Concern Diverticulitis Concern Rectal Pain And Anorectal Complaints Dysphagia And Food Bolus Impaction Foreign Body Ingestion Refractory Vomiting And Recurrent Vomiting Syndromes Cannabis Associated Hyperemesis Upper Gastrointestinal Bleeding Symptoms (melena)Lower Gastrointestinal Bleeding And Hematochezia Constipation And Obstipation Diarrhea Acute Hepatitis And Jaundice Concern Right Upper Quadrant Pain Epigastric Pain Left Upper Quadrant Pain Right Lower Quadrant Pain Left Lower Quadrant Pain Suprapubic Pain

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx71

HPI overview

›Key features

›Pain location

›Pain trajectory

›Prior similar episodes

›Baseline functional status

OPQRST

›Onset

›Sudden onset

›Gradual onset

›Time since onset

›Provocation and palliation

›Postprandial association

›Fatty food trigger

›Relief with vomiting

›Worse with inspiration

›Quality

›Colicky

›Constant

›Burning

›Pleuritic

›Region and radiation

›Right scapular radiation

›Epigastric radiation

›Back radiation

›Chest radiation

›Severity

›Max severity at onset

›Current severity

›Analgesic response

›Timing

›Duration of episodes

›Nocturnal episodes

›Progressive worsening

Associated symptoms

›GI and hepatobiliary

›Nausea

›Vomiting

›Anorexia

›Jaundice

›Pale stools

›Dark urine

›Infection and systemic

›Fever

›Rigors

›Night sweats

›Cardiorespiratory

›Dyspnea

›Pleuritic chest pain

›Cough

›GU and gyn

›Dysuria

›Flank pain

›Vaginal bleeding

›Pregnancy possibility

Context and exposures

›Recent events

›Recent travel

›Sick contacts

›Recent antibiotics

›Recent procedures

›Food and toxin exposures

›Alcohol binge

›Suspected foodborne illness

›Acetaminophen exposure

Special populations

›Pregnancy

›Gestational age

›Preeclampsia symptoms

›Prior pregnancy complications

›Immunocompromised

›Neutropenia risk

›Transplant history

›Anticoagulated

›Anticoagulant type

›Last dose timing

02Alarm Features/alarm28

Immediate escalation triggers

›Resuscitation triggers

›SBP under 90 mmHg

›HR over 130 per minute

›SpO2 under 92 percent on room air

›New altered mental status

›Persistent severe pain despite analgesia

Sepsis and cholangitis red flags

›High risk infection features

›Fever with jaundice

›Rigors

›Hypotension

›Confusion

Vascular catastrophe red flags

›Aortic and mesenteric concern

›Sudden tearing chest or back pain

›Syncope

›Pulse deficit

›Focal neurologic deficit

›Pain out of proportion to exam

Peritonitis and perforation red flags

›Surgical abdomen features

›Rebound tenderness

›Guarding

›Rigid abdomen

›Involuntary guarding

Cardiac and pulmonary red flags

›High risk cardiopulmonary features

›Exertional chest discomfort

›Diaphoresis

›New ischemic ECG changes

›Hemoptysis

›Unilateral leg swelling

03Medications/meds17

Medication reconciliation

›Current medications

›Prescription medications

›OTC medications

›Supplements

High risk medication exposures

›Hepatobiliary relevant meds

›Acetaminophen

›Statins

›Antiepileptics

›Herbal supplements

›Bleeding risk meds

›Warfarin

›DOACs

›Antiplatelets

Contraindications and interactions

›Common ED therapies

›NSAID avoidance with CKD or GI bleed risk

›Opioid caution with respiratory depression risk

›QT prolongation risk with antiemetics

04Diet/diet8

Recent intake and triggers

›Patterns

›Fatty meal trigger

›Large meal trigger

›Fasting or poor intake

Hydration and alcohol

›Exposures

›Low oral intake

›Vomiting related dehydration

›Recent alcohol use

05Review of Systems/ros25

GI and hepatobiliary

›Key symptoms

›Nausea

›Vomiting

›Diarrhea

›Constipation

›Hematemesis

›Melena

Constitutional and infectious

›Systemic symptoms

›Fever

›Chills

›Weight loss

Cardiorespiratory

›Chest and lung symptoms

›Chest pain

›Dyspnea

›Cough

›Pleuritic pain

GU and gyn

›GU and pelvic symptoms

›Dysuria

›Flank pain

›Vaginal bleeding

›Pelvic pain

Skin and neuro

›Other symptoms

›Vesicular rash

›Headache

›Focal weakness

06Collateral History and Family History/chafh9

Collateral source

›Reliability

›Family report available

›EMS report available

›Facility documentation available

Family history

›Relevant conditions

›Early coronary disease

›Gallstone disease

›Hemochromatosis

›Thrombophilia

07Risk Factors/rf24

Hepatobiliary and pancreatic

›Gallstone risk

›Prior gallstones

›Rapid weight loss

›Pregnancy

›Estrogen exposure

›Pancreatitis risk

›Alcohol use disorder

›Hypertriglyceridemia history

Infection and obstruction

›Biliary infection risk

›Known choledocholithiasis

›Prior ERCP or stent

›Prior cholangitis

Vascular and thrombotic

›Thromboembolism risk

›Recent surgery or immobilization

›Active malignancy

›Prior VTE

›Aortic risk

›Known aneurysm

›Connective tissue disorder

›Longstanding hypertension (I10)

Cardiac risk

›Coronary risk factors

›Diabetes mellitus type 2 (E11.9)

›Smoking

›Hyperlipidemia (E78.5)

08Differential Diagnosis/ddx66

Life threatening

›Cannot miss

›Ascending cholangitis (K83.09)

›Fever with jaundice

›Hypotension or confusion

›Acute cholecystitis with complications (K81.0)

›Persistent RUQ pain over 6 hours

›Peritonitis signs

›Acute pancreatitis (K85.9)

›Epigastric or RUQ pain radiating to back

›Lipase elevation

›Acute coronary syndrome (I24.9)

›Epigastric or RUQ discomfort in high risk patient

›ECG changes or troponin rise

›Pulmonary embolism (I26.99)

›Pleuritic RUQ pain with dyspnea

›Tachycardia and hypoxemia

›Pneumonia with pleurisy (J18.9)

›RUQ pain with cough or fever

›Focal lung findings

›Aortic dissection (I71.00)

›Sudden severe chest or back pain

›Pulse deficit or neuro deficit

›Abdominal aortic aneurysm rupture (I71.3)

›Hypotension with abdominal or back pain

›Syncope

›Mesenteric ischemia (K55.9)

›Pain out of proportion

›Lactate elevation

›HELLP syndrome (O14.2)

›Pregnancy with RUQ pain

›Hypertension and lab abnormalities

Common

›Frequent causes

›Biliary colic (K80.20)

›Postprandial episodic RUQ pain

›Pain resolves within hours

›Acute cholecystitis (K81.0)

›RUQ pain with fever

›Positive Murphy sign

›Acute hepatitis (K75.9)

›Malaise with jaundice

›Marked transaminase rise

›GERD or gastritis (K21.9)

›Burning epigastric pain

›Meal related symptoms

›Renal colic (N20.0)

›Flank to groin radiation

›Hematuria

›Pyelonephritis (N10)

›Fever with CVA tenderness

›Pyuria

›Herpes zoster (B02.9)

›Dermatomal pain

›Vesicular rash

Less common

›Important alternatives

›Liver abscess (K75.0)

›Fever with RUQ pain

›Risk with biliary disease or bacteremia

›Budd-Chiari syndrome (I82.0)

›RUQ pain with hepatomegaly

›Ascites

›Fitz-Hugh-Curtis syndrome (A54.86)

›RUQ pain with PID symptoms

›Cervical motion tenderness

›Hepatic malignancy

›Weight loss

›Persistent RUQ discomfort

09Past Medical History/pmh12

Relevant conditions

›Hepatobiliary history

›Known gallstones

›Prior cholecystitis

›Prior cholangitis

›Prior pancreatitis

›Cardiac and vascular history

›Coronary artery disease (I25.10)

›Aortic aneurysm history

›Surgical and device history

›Cholecystectomy status

›ERCP or biliary stent history

›Abdominal surgeries

10Physical Exam/exam26

General and vitals interpretation

›Appearance and perfusion

›Toxic appearance

›Diaphoresis

›Delayed capillary refill

›Vital sign patterns

›Fever

›Hypotension

›Tachycardia

Abdominal exam

›RUQ focused findings

›RUQ tenderness

›Murphy sign

›Guarding

›Rebound tenderness

›Hepatobiliary signs

›Jaundice

›Hepatomegaly

Cardiorespiratory exam

›Heart and lungs

›Rales or focal crackles

›Pleural rub

›New murmur

Skin and neuro

›Targeted findings

›Vesicular rash

›Altered mental status

Extremities and vascular

›Perfusion and thrombosis

›Asymmetric pulses

›Unilateral leg swelling

11Lab Studies/labs29

Core labs

›Baseline evaluation

›CBC

›Electrolytes

›Creatinine

›Glucose

›Hepatobiliary panel

›AST

›ALT

›ALP

›Total bilirubin

›Direct bilirubin

›Pancreatic and perfusion

›Lipase

›Lactate

›Coagulation and pregnancy

›INR

›Pregnancy test when applicable

Infection and sepsis workup

›When febrile or unstable

›Blood cultures

›Venous blood gas

›Repeat lactate timing based on trajectory

Interpretation pearls

›Pattern recognition

›Cholestatic pattern with ALP and bilirubin predominant

›Hepatocellular pattern with AST and ALT predominant

›Leukocytosis supports infection but not required

Pitfalls

›Limitations

›Early biliary disease with normal labs

›Lipase can be normal early in pancreatitis

›Marked AST and ALT rise can occur with transient CBD stone

12Imaging/img30

Scoring Systems

›Severity and criteria tools

›Tokyo Guidelines severity grading for acute cholangitis

›Tokyo Guidelines diagnostic criteria for acute cholecystitis

›Local protocol dependent pathways for biliary disease disposition

MRI

›MRCP

›Suspected choledocholithiasis with nondiagnostic ultrasound

›Avoid gadolinium when severe renal impairment

›High sensitivity for biliary obstruction patterns

›CT abdomen pelvis with IV contrast

›Alternative diagnosis concern

›Complications concern

›Caution with contrast allergy

›Caution with renal impairment

›CT angiography chest abdomen pelvis

›Aortic dissection concern

›Mesenteric ischemia concern

›Radiation and contrast risk discussion when stable

Ultrasound

›RUQ ultrasound

›First line for suspected gallbladder disease

›Gallstones

›Gallbladder wall thickening

›Pericholecystic fluid

›Sonographic Murphy sign

›POCUS gallbladder and biliary

›Screening for gallstones

›CBD dilation proxy

›Pitfall with obesity and bowel gas

›Ultrasound aorta

›Rapid screen for AAA

›Limited for dissection

13Special Tests/spec11

Bedside maneuvers

›Focused tests

›Murphy sign

›Carnett sign for abdominal wall pain

›CVA tenderness

Targeted serologies and toxicology

›When indicated

›Viral hepatitis panel

›Acetaminophen level with exposure concern

›HIV testing based on risk and consent

Procedures

›Diagnostic and therapeutic pathways

›ERCP for cholangitis or obstructing CBD stone

›HIDA scan for equivocal ultrasound and persistent suspicion

14ECG/ecg8

Indications and timing

›When to obtain

›RUQ or epigastric pain in older adults

›Any cardiopulmonary symptoms

›High risk cardiovascular history

High risk patterns

›Ischemia and conduction

›Inferior STEMI pattern

›New ST depression or T wave inversion

›New LBBB pattern

15Assessment/ax14

Working problem list

›RUQ pain syndrome

›Biliary colic versus cholecystitis

›Hepatitis versus cholangitis

›Pancreatitis consideration

›Alternate life threats

›ACS mimic evaluation status

›PE mimic evaluation status

›Aortic pathology evaluation status

Severity stratification

›Infection severity

›Sepsis criteria present

›Organ dysfunction features present

›Obstruction concern

›Jaundice with cholestatic labs

›CBD dilation on imaging

16Plan/plan26

First 5 minutes

›Stabilization

›Cardiac monitor when unstable or high risk

›IV access

›Fluid bolus for hypotension

›Oxygen for SpO2 under 92 percent

Analgesia and antiemetics

›Symptom control

›Acetaminophen PO or IV 1000 mg once

›Ketorolac IV 15 mg once if no contraindication

›Hydromorphone IV 0.5 mg once with reassessment

›Ondansetron IV 4 mg once

Antibiotics

›Suspected cholecystitis or cholangitis

›Ceftriaxone IV 2 g once daily

›Metronidazole IV 500 mg every 8 hours

›Piperacillin tazobactam IV 4.5 g every 6 hours as alternative

Diagnostic sequencing

›Testing priorities

›ECG and troponin when ACS risk

›RUQ ultrasound first line for biliary disease

›CT abdomen pelvis with contrast when alternative diagnosis or complications concern

Consultation

›Time critical consults

›GI for cholangitis and ERCP pathway

›Surgery for cholecystitis and complications

›Vascular surgery for AAA or dissection concern

Reassessment loop

›Repeat checks

›Pain score and abdominal exam after analgesia

›Vital signs trending every 30 to 60 minutes when acute

›Urine output monitoring when septic or dehydrated

17Disposition/dispo18

ICU and high acuity criteria

›Critical care needs

›Vasopressor requirement

›Persistent hypotension after fluids

›Rising lactate despite resuscitation

Admission criteria

›Inpatient indications

›Acute cholecystitis

›Suspected cholangitis

›Pancreatitis with systemic features

›Uncontrolled pain or vomiting

Observation criteria

›Short stay pathways

›Biliary colic with recurrent symptoms

›Equivocal imaging with stable vitals

Discharge criteria

›Safe discharge features

›Pain controlled with oral meds

›No fever

›No jaundice

›Tolerating oral intake

›Reliable follow up within 48 to 72 hours

18Discharge Instructions/di12

Copy discharge instructions

›Summary

›You were seen for right upper abdominal pain and your tests did not show an emergency today

›Return now for worsening pain, fainting, trouble breathing, chest pain, fever, confusion, yellow skin or eyes, or repeated vomiting

›Medications

›Use acetaminophen as directed on the label

›Avoid NSAIDs if you have kidney disease, stomach ulcer history, or are on blood thinners

›Diet and activity

›Clear fluids then advance as tolerated

›Avoid fatty meals until follow up

›Follow up

›Primary care or surgery clinic within 48 to 72 hours if gallbladder disease suspected

›Return for any new jaundice or dark urine

19References/r15

Guidelines and key sources

›Tokyo Guidelines 2018 for acute cholangitis and acute cholecystitis

›Diagnostic criteria and severity grading framework

›Antibiotic and biliary drainage timing concepts

›World Society of Emergency Surgery guidelines for acute calculous cholecystitis 2020

›Imaging first line and operative timing concepts

›Severity based management pathways

›American College of Gastroenterology guideline for acute pancreatitis 2013

›Diagnostic criteria and early management principles

›Severity stratification concepts

›Surviving Sepsis Campaign guidelines 2021

›Sepsis recognition and resuscitation targets

›Antibiotic timing principles

›American Heart Association and ACC guidance for ACS evaluation

›Atypical presentations in older adults and diabetics

›ECG and troponin based risk evaluation

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Right Upper Quadrant PainAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

449 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx71

HPI overview

›Key features

›Pain location

›Pain trajectory

›Prior similar episodes

›Baseline functional status

OPQRST

›Onset

›Sudden onset

›Gradual onset

›Time since onset

›Provocation and palliation

›Postprandial association

›Fatty food trigger

›Relief with vomiting

›Worse with inspiration

›Quality

›Colicky

›Constant

›Burning

›Pleuritic

›Region and radiation

›Right scapular radiation

›Epigastric radiation

›Back radiation

›Chest radiation

›Severity

›Max severity at onset

›Current severity

›Analgesic response

›Timing

›Duration of episodes

›Nocturnal episodes

›Progressive worsening

Associated symptoms

›GI and hepatobiliary

›Nausea

›Vomiting

›Anorexia

›Jaundice

›Pale stools

›Dark urine

›Infection and systemic

›Fever

›Rigors

›Night sweats

›Cardiorespiratory

›Dyspnea

›Pleuritic chest pain

›Cough

›GU and gyn

›Dysuria

›Flank pain

›Vaginal bleeding

›Pregnancy possibility

Context and exposures

›Recent events

›Recent travel

›Sick contacts

›Recent antibiotics

›Recent procedures

›Food and toxin exposures

›Alcohol binge

›Suspected foodborne illness

›Acetaminophen exposure

Special populations

›Pregnancy

›Gestational age

›Preeclampsia symptoms

›Prior pregnancy complications

›Immunocompromised

›Neutropenia risk

›Transplant history

›Anticoagulated

›Anticoagulant type

›Last dose timing

02Alarm Features/alarm28

Immediate escalation triggers

›Resuscitation triggers

›SBP under 90 mmHg

›HR over 130 per minute

›SpO2 under 92 percent on room air

›New altered mental status

›Persistent severe pain despite analgesia

Sepsis and cholangitis red flags

›High risk infection features

›Fever with jaundice

›Rigors

›Hypotension

›Confusion

Vascular catastrophe red flags

›Aortic and mesenteric concern

›Sudden tearing chest or back pain

›Syncope

›Pulse deficit

›Focal neurologic deficit

›Pain out of proportion to exam

Peritonitis and perforation red flags

›Surgical abdomen features

›Rebound tenderness

›Guarding

›Rigid abdomen

›Involuntary guarding

Cardiac and pulmonary red flags

›High risk cardiopulmonary features

›Exertional chest discomfort

›Diaphoresis

›New ischemic ECG changes

›Hemoptysis

›Unilateral leg swelling

03Medications/meds17

Medication reconciliation

›Current medications

›Prescription medications

›OTC medications

›Supplements

High risk medication exposures

›Hepatobiliary relevant meds

›Acetaminophen

›Statins

›Antiepileptics

›Herbal supplements

›Bleeding risk meds

›Warfarin

›DOACs

›Antiplatelets

Contraindications and interactions

›Common ED therapies

›NSAID avoidance with CKD or GI bleed risk

›Opioid caution with respiratory depression risk

›QT prolongation risk with antiemetics

04Diet/diet8

Recent intake and triggers

›Patterns

›Fatty meal trigger

›Large meal trigger

›Fasting or poor intake

Hydration and alcohol

›Exposures

›Low oral intake

›Vomiting related dehydration

›Recent alcohol use

05Review of Systems/ros25

GI and hepatobiliary

›Key symptoms

›Nausea

›Vomiting

›Diarrhea

›Constipation

›Hematemesis

›Melena

Constitutional and infectious

›Systemic symptoms

›Fever

›Chills

›Weight loss

Cardiorespiratory

›Chest and lung symptoms

›Chest pain

›Dyspnea

›Cough

›Pleuritic pain

GU and gyn

›GU and pelvic symptoms

›Dysuria

›Flank pain

›Vaginal bleeding

›Pelvic pain

Skin and neuro

›Other symptoms

›Vesicular rash

›Headache

›Focal weakness

06Collateral History and Family History/chafh9

Collateral source

›Reliability

›Family report available

›EMS report available

›Facility documentation available

Family history

›Relevant conditions

›Early coronary disease

›Gallstone disease

›Hemochromatosis

›Thrombophilia

07Risk Factors/rf24

Hepatobiliary and pancreatic

›Gallstone risk

›Prior gallstones

›Rapid weight loss

›Pregnancy

›Estrogen exposure

›Pancreatitis risk

›Alcohol use disorder

›Hypertriglyceridemia history

Infection and obstruction

›Biliary infection risk

›Known choledocholithiasis

›Prior ERCP or stent

›Prior cholangitis

Vascular and thrombotic

›Thromboembolism risk

›Recent surgery or immobilization

›Active malignancy

›Prior VTE

›Aortic risk

›Known aneurysm

›Connective tissue disorder

›Longstanding hypertension (I10)

Cardiac risk

›Coronary risk factors

›Diabetes mellitus type 2 (E11.9)

›Smoking

›Hyperlipidemia (E78.5)

08Differential Diagnosis/ddx66

Life threatening

›Cannot miss

›Ascending cholangitis (K83.09)

›Fever with jaundice

›Hypotension or confusion

›Acute cholecystitis with complications (K81.0)

›Persistent RUQ pain over 6 hours

›Peritonitis signs

›Acute pancreatitis (K85.9)

›Epigastric or RUQ pain radiating to back

›Lipase elevation

›Acute coronary syndrome (I24.9)

›Epigastric or RUQ discomfort in high risk patient

›ECG changes or troponin rise

›Pulmonary embolism (I26.99)

›Pleuritic RUQ pain with dyspnea

›Tachycardia and hypoxemia

›Pneumonia with pleurisy (J18.9)

›RUQ pain with cough or fever

›Focal lung findings

›Aortic dissection (I71.00)

›Sudden severe chest or back pain

›Pulse deficit or neuro deficit

›Abdominal aortic aneurysm rupture (I71.3)

›Hypotension with abdominal or back pain

›Syncope

›Mesenteric ischemia (K55.9)

›Pain out of proportion

›Lactate elevation

›HELLP syndrome (O14.2)

›Pregnancy with RUQ pain

›Hypertension and lab abnormalities

Common

›Frequent causes

›Biliary colic (K80.20)

›Postprandial episodic RUQ pain

›Pain resolves within hours

›Acute cholecystitis (K81.0)

›RUQ pain with fever

›Positive Murphy sign

›Acute hepatitis (K75.9)

›Malaise with jaundice

›Marked transaminase rise

›GERD or gastritis (K21.9)

›Burning epigastric pain

›Meal related symptoms

›Renal colic (N20.0)

›Flank to groin radiation

›Hematuria

›Pyelonephritis (N10)

›Fever with CVA tenderness

›Pyuria

›Herpes zoster (B02.9)

›Dermatomal pain

›Vesicular rash

Less common

›Important alternatives

›Liver abscess (K75.0)

›Fever with RUQ pain

›Risk with biliary disease or bacteremia

›Budd-Chiari syndrome (I82.0)

›RUQ pain with hepatomegaly

›Ascites

›Fitz-Hugh-Curtis syndrome (A54.86)

›RUQ pain with PID symptoms

›Cervical motion tenderness

›Hepatic malignancy

›Weight loss

›Persistent RUQ discomfort

09Past Medical History/pmh12

Relevant conditions

›Hepatobiliary history

›Known gallstones

›Prior cholecystitis

›Prior cholangitis

›Prior pancreatitis

›Cardiac and vascular history

›Coronary artery disease (I25.10)

›Aortic aneurysm history

›Surgical and device history

›Cholecystectomy status

›ERCP or biliary stent history

›Abdominal surgeries

10Physical Exam/exam26

General and vitals interpretation

›Appearance and perfusion

›Toxic appearance

›Diaphoresis

›Delayed capillary refill

›Vital sign patterns

›Fever

›Hypotension

›Tachycardia

Abdominal exam

›RUQ focused findings

›RUQ tenderness

›Murphy sign

›Guarding

›Rebound tenderness

›Hepatobiliary signs

›Jaundice

›Hepatomegaly

Cardiorespiratory exam

›Heart and lungs

›Rales or focal crackles

›Pleural rub

›New murmur

Skin and neuro

›Targeted findings

›Vesicular rash

›Altered mental status

Extremities and vascular

›Perfusion and thrombosis

›Asymmetric pulses

›Unilateral leg swelling

11Lab Studies/labs29

Core labs

›Baseline evaluation

›CBC

›Electrolytes

›Creatinine

›Glucose

›Hepatobiliary panel

›AST

›ALT

›ALP

›Total bilirubin

›Direct bilirubin

›Pancreatic and perfusion

›Lipase

›Lactate

›Coagulation and pregnancy

›INR

›Pregnancy test when applicable

Infection and sepsis workup

›When febrile or unstable

›Blood cultures

›Venous blood gas

›Repeat lactate timing based on trajectory

Interpretation pearls

›Pattern recognition

›Cholestatic pattern with ALP and bilirubin predominant

›Hepatocellular pattern with AST and ALT predominant

›Leukocytosis supports infection but not required

Pitfalls

›Limitations

›Early biliary disease with normal labs

›Lipase can be normal early in pancreatitis

›Marked AST and ALT rise can occur with transient CBD stone

12Imaging/img30

Scoring Systems

›Severity and criteria tools

›Tokyo Guidelines severity grading for acute cholangitis

›Tokyo Guidelines diagnostic criteria for acute cholecystitis

›Local protocol dependent pathways for biliary disease disposition

MRI

›MRCP

›Suspected choledocholithiasis with nondiagnostic ultrasound

›Avoid gadolinium when severe renal impairment

›High sensitivity for biliary obstruction patterns

›CT abdomen pelvis with IV contrast

›Alternative diagnosis concern

›Complications concern

›Caution with contrast allergy

›Caution with renal impairment

›CT angiography chest abdomen pelvis

›Aortic dissection concern

›Mesenteric ischemia concern

›Radiation and contrast risk discussion when stable

Ultrasound

›RUQ ultrasound

›First line for suspected gallbladder disease

›Gallstones

›Gallbladder wall thickening

›Pericholecystic fluid

›Sonographic Murphy sign

›POCUS gallbladder and biliary

›Screening for gallstones

›CBD dilation proxy

›Pitfall with obesity and bowel gas

›Ultrasound aorta

›Rapid screen for AAA

›Limited for dissection

13Special Tests/spec11

Bedside maneuvers

›Focused tests

›Murphy sign

›Carnett sign for abdominal wall pain

›CVA tenderness

Targeted serologies and toxicology

›When indicated

›Viral hepatitis panel

›Acetaminophen level with exposure concern

›HIV testing based on risk and consent

Procedures

›Diagnostic and therapeutic pathways

›ERCP for cholangitis or obstructing CBD stone

›HIDA scan for equivocal ultrasound and persistent suspicion

14ECG/ecg8

Indications and timing

›When to obtain

›RUQ or epigastric pain in older adults

›Any cardiopulmonary symptoms

›High risk cardiovascular history

High risk patterns

›Ischemia and conduction

›Inferior STEMI pattern

›New ST depression or T wave inversion

›New LBBB pattern

15Assessment/ax14

Working problem list

›RUQ pain syndrome

›Biliary colic versus cholecystitis

›Hepatitis versus cholangitis

›Pancreatitis consideration

›Alternate life threats

›ACS mimic evaluation status

›PE mimic evaluation status

›Aortic pathology evaluation status

Severity stratification

›Infection severity

›Sepsis criteria present

›Organ dysfunction features present

›Obstruction concern

›Jaundice with cholestatic labs

›CBD dilation on imaging

16Plan/plan26

First 5 minutes

›Stabilization

›Cardiac monitor when unstable or high risk

›IV access

›Fluid bolus for hypotension

›Oxygen for SpO2 under 92 percent

Analgesia and antiemetics

›Symptom control

›Acetaminophen PO or IV 1000 mg once

›Ketorolac IV 15 mg once if no contraindication

›Hydromorphone IV 0.5 mg once with reassessment

›Ondansetron IV 4 mg once

Antibiotics

›Suspected cholecystitis or cholangitis

›Ceftriaxone IV 2 g once daily

›Metronidazole IV 500 mg every 8 hours

›Piperacillin tazobactam IV 4.5 g every 6 hours as alternative

Diagnostic sequencing

›Testing priorities

›ECG and troponin when ACS risk

›RUQ ultrasound first line for biliary disease

›CT abdomen pelvis with contrast when alternative diagnosis or complications concern

Consultation

›Time critical consults

›GI for cholangitis and ERCP pathway

›Surgery for cholecystitis and complications

›Vascular surgery for AAA or dissection concern

Reassessment loop

›Repeat checks

›Pain score and abdominal exam after analgesia

›Vital signs trending every 30 to 60 minutes when acute

›Urine output monitoring when septic or dehydrated

17Disposition/dispo18

ICU and high acuity criteria

›Critical care needs

›Vasopressor requirement

›Persistent hypotension after fluids

›Rising lactate despite resuscitation

Admission criteria

›Inpatient indications

›Acute cholecystitis

›Suspected cholangitis

›Pancreatitis with systemic features

›Uncontrolled pain or vomiting

Observation criteria

›Short stay pathways

›Biliary colic with recurrent symptoms

›Equivocal imaging with stable vitals

Discharge criteria

›Safe discharge features

›Pain controlled with oral meds

›No fever

›No jaundice

›Tolerating oral intake

›Reliable follow up within 48 to 72 hours

18Discharge Instructions/di12

Copy discharge instructions

›Summary

›You were seen for right upper abdominal pain and your tests did not show an emergency today

›Return now for worsening pain, fainting, trouble breathing, chest pain, fever, confusion, yellow skin or eyes, or repeated vomiting

›Medications

›Use acetaminophen as directed on the label

›Avoid NSAIDs if you have kidney disease, stomach ulcer history, or are on blood thinners

›Diet and activity

›Clear fluids then advance as tolerated

›Avoid fatty meals until follow up

›Follow up

›Primary care or surgery clinic within 48 to 72 hours if gallbladder disease suspected

›Return for any new jaundice or dark urine

19References/r15

Guidelines and key sources

›Tokyo Guidelines 2018 for acute cholangitis and acute cholecystitis

›Diagnostic criteria and severity grading framework

›Antibiotic and biliary drainage timing concepts

›World Society of Emergency Surgery guidelines for acute calculous cholecystitis 2020

›Imaging first line and operative timing concepts

›Severity based management pathways

›American College of Gastroenterology guideline for acute pancreatitis 2013

›Diagnostic criteria and early management principles

›Severity stratification concepts

›Surviving Sepsis Campaign guidelines 2021

›Sepsis recognition and resuscitation targets

›Antibiotic timing principles

›American Heart Association and ACC guidance for ACS evaluation

›Atypical presentations in older adults and diabetics

›ECG and troponin based risk evaluation

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.