Biliary tract disease leads to intermittent acute pain that is usually localized to the right upper quadrant or the epigastric area that lasts for 15 minutes or a few hours. The pain may radiate to the back or scapula and is often associated with restlessness, sweating, or vomiting. Episodes are typically separated by weeks to months. A history of recurrent pancreatitis or excessive alcohol in- take should raise the possibility of chronic pancreatitis. Upper GI symptoms can be related to ulcer or nonulcer dyspepsia. Postprandial abdominal pain may be related to underlying chronic intestinal ischemia, gastroparesis,
intermittent intestinal obstruction, pancreatitis, or peptic ulcer disease. Features that suggest organic illness include unstable weight loss, fever, dehydration, electrolyte abnormalities, symptoms or signs of GI blood loss, anemia, and signs of malnutrition and abnormal physical findings.
Routine laboratory testing is mandatory to evaluate for any underlying disease process. CBC, basal metabolic panel (BMP), liver function tests, amylase, and urinalysis (including porphobilinogen in cases of suspected acute intermittent porphyria) are needed. Stool analysis for leucocytes, ova, and parasites should be obtained as clinically indicated. Diagnostic imaging studies such as abdominal x-ray films, abdominal ultra- sonography, CT scan of the abdomen, upper GI series with small bowel follow-through, or MRI may be indicated. Endoscopic studies, including upper, lower, capsule endoscopy and endoscopic retrograde cholangiopancreatography (ERCP), are also performed according to each clinical setting.