How Should I Image the Patient with Suspected Liver or Biliary Disease?

  • Thompson KehrlEmail author
  • Mark Collin
  • Timothy Jang


Patients with right upper quadrant pain presenting for emergency care frequently require imaging. Understanding the pros and cons of the potential imaging modalities is key to appropriate evaluation and management. Ultrasound is often recommended as the initial test of choice in these patients. Ultrasound excels when evaluating for cholelithiasis and cholecystitis. Computerized tomography is considered second line but is frequently employed in equivocal cases. Understanding limitations and pitfalls of these studies is imperative.


Right upper quadrant Abdominal pain Ultrasound Cholelithiasis choledocholithiasis 


  1. 1.
    Yarmish GM, Smith MP, Rosen MP, et al. ACR appropriateness criteria right upper quadrant pain. J Am Coll Radiol. 2014;11:316–22.CrossRefGoogle Scholar
  2. 2.
    Ross M, Brown M, McLaughlin K, Atkinson P, Thompson J, Powelson S, Clark S, Lang E. Emergency physician-performed ultrasound to diagnose cholelithiasis: a systemic review. Acad Emerg Med. 2011;18:227–35.CrossRefGoogle Scholar
  3. 3.
    Jain A, Mehta N, Secko M, Schechter J, Papanagnou D, Pandya S, Sinert R. History, physical examination, laboratory testing, and emergency department. Ultrasonography for the diagnosis of acute cholecystitis. Acad Emerg Med. 2017;24(3):281–97.CrossRefGoogle Scholar
  4. 4.
    Bisset RA, Khan AN. Differential diagnosis in abdominal ultrasound, vol. 202. Long: WB Saunders. p. 159–80.Google Scholar
  5. 5.
    Scott MA, Farrands PA, Guyer PB, et al. Ultrasound of the common bile duct in patients undergoing cholecystectomy. J Clin Ultrasound. 1991;19:73–6.CrossRefGoogle Scholar
  6. 6.
    Dong B, Chen M. Improved sonographic visualization of choledocholithiasis. J Clin Ultrasound. 1987;15:185–90.CrossRefGoogle Scholar
  7. 7.
    Gurusamy KD, Giljaca V, Takwoingi Y, et al. Ultrasound versus liver function tests for diagnosis of common bile duct stones. Cochrane Database Syst Rev. 2015;2:1–57.Google Scholar
  8. 8.
    Lal N, Mehra S, Lal V. Ultrasonographic measurement of normal common bile duct diameter and its correlation with age, sex and anthropometry. J Clin Diagn Res. 2014;8:AC01–4.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Lee DH, Ahn YJ, Lee HW, et al. Prevalence and characteristics of clinically significant retained common bile duct stones after laparoscopic cholecystectomy for symptomatic cholelithiasis. Ann Surg Treat Res. 2016;91:239–46.CrossRefGoogle Scholar
  10. 10.
    Thurley PD, Dhingsa R. Laparoscopic cholecystectomy: post-operative imaging. Am J Roentgenol. 2008;191:794–801.CrossRefGoogle Scholar
  11. 11.
    Kimura Y, Takada T, Kawarada Y, et al. Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo guidelines. J Hepato-Biliary-Pancreat Surg. 2007;14:15–26.CrossRefGoogle Scholar
  12. 12.
    Amitrano L, Guardascione MA, Brancaccio V, et al. Risk factors and clinical presentation of portal vein thrombosis in patients with liver cirrhosis. J Hepatol. 2004;40:736–41.CrossRefGoogle Scholar
  13. 13.
    Altemeier WA, Culbertson WR, Fullen WD, et al. Intra-abdominal abscesses. Am J Surg. 1973;125:70–9.CrossRefGoogle Scholar
  14. 14.
    Bloom AA, Remy P. Emphysematous cholecystitis. Medscape 2015 Accessed 20 Dec 2017.
  15. 15.
    Paulson EK. Acute cholecystitis: CT findings. Semin Ultrasound CT MR. 2000;21:56–63.CrossRefGoogle Scholar
  16. 16.
    Kiewiet JJ, Leeuwenburgh MM, Bipat S, Bossuyt PM, Stoker J, Boermeester MA. A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology. 2012;264:708–20.CrossRefGoogle Scholar
  17. 17.
    Sorenson MK, Fancher S, Lang NP, Eidt JF, Broadwater JR. Abnormal gallbladder nuclear ejection fraction predicts success of cholecystectomy in patients with biliary dyskinesia. Am J Surg. 1993;166:672–4.CrossRefGoogle Scholar
  18. 18.
    Mahid SS, Jafri NS, Brangers BC, Minor KS, Hornung CA, Galandiuk S. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009;144:180–7.CrossRefGoogle Scholar
  19. 19.
    Aube C, Delorme B, Yzet T, et al. MR cholangiopancreatography versus endoscopic sonography in suspected common bile duct lithiasis: a prospective, comparative study. Am J Roentgenol. 2005;184:55–62.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Section of Emergency UltrasoundYork Hospital Emergency Ultrasound Fellowship, York Hospital Emergency Medicine Residency, York Hospital Department of Emergency MedicineYorkUSA
  2. 2.Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLATorranceUSA

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