Gallstones affect approximately 10–15% of adults and represent a frequent cause of right upper quadrant (RUQ) pain. Ultrasound is recommended as the first-line diagnostic modality for suspected biliary disease, yet access may be limited in rural settings due to cost, transportation barriers, and lack of laboratory services. Handheld point-of-care ultrasound (POCUS) offers rapid bedside evaluation and may bridge diagnostic gaps when cart-based systems are unavailable. Although the literature increasingly supports POCUS for biliary assessment, its real-world implementation in low-resource environments remains under-reported. This case report aims to discuss the utility of POCUS for biliary diagnosis in low-resource settings. A 71-year-old woman with no comorbidities presented with one day of acute RUQ pain. She denied fever, nausea, or vomiting. Vital signs were stable. Physical examination demonstrated positive Murphy’s and Lloyd’s signs without rebound tenderness. Laboratory testing was not available at the clinical site, necessitating a diagnosis informed solely by bedside imaging and physical examination. A handheld abdominal ultrasound (Butterfly iQ3, abdomen preset) was performed with the patient supine. Imaging revealed three mobile hyperechoic gallstones measuring approximately 1.5 cm each with posterior acoustic shadowing, gallbladder wall thickening of 5 mm, and a positive sonographic Murphy’s sign. No biliary ductal dilation was noted. In the absence of systemic inflammation or evidence of obstruction, findings were most consistent with symptomatic cholelithiasis versus early cholecystitis. Alternative causes of RUQ pain, including hepatic, renal, peritoneal, peptic, or pulmonary etiologies, were considered less likely based on imaging and clinical context. The patient received analgesia with improvement and was discharged with expedited gastroenterology referral for cholecystectomy. Follow-up was limited due to temporary clinic operations. This case highlights the utility of handheld POCUS in rural settings, supporting timely diagnosis, reducing barriers to care, and demonstrating its potential to improve clinical decision-making in rural settings.
