What is the most appropriate next step for a vitally stable patient with mild abdominal pain, mainly in the right upper quadrant, after a recent road traffic accident (RTA)?

Abdominal Ultrasound is the Most Appropriate Next Step

For a vitally stable patient with mild right upper quadrant pain after recent trauma, obtain an abdominal ultrasound immediately as the first-line diagnostic study. 1, 2, 3

Rationale for Ultrasound as First-Line Imaging

• Ultrasound is the primary imaging modality with 96% accuracy for diagnosing gallstones and hepatobiliary pathology, and should be performed first in all patients with RUQ pain. 1, 3
• The American College of Radiology and American Academy of Family Physicians both give ultrasound the highest appropriateness rating (9/9) for right upper quadrant pain evaluation. 2, 3, 4
• Ultrasound provides rapid, cost-effective diagnosis without radiation exposure, making it ideal for initial evaluation in stable patients. 1
• This imaging can identify gallbladder pathology, liver abnormalities, free fluid, and other causes of RUQ pain that may be trauma-related or incidental. 2, 3

Why Not Emergency Department Referral?

• The patient is vitally stable with only mild pain, which does not meet criteria for immediate emergency department transfer. 1, 2
• Stable vital signs indicate no active hemorrhage or life-threatening condition requiring emergent intervention. 1
• You can appropriately initiate the diagnostic workup in your clinic setting with ultrasound, which is the recommended first step regardless of setting. 1, 3

Why Not Blood Work Alone?

• Laboratory testing should accompany ultrasound imaging, not replace it, as imaging is essential for diagnosing the cause of RUQ pain. 2, 3
• While CBC, liver function tests, and pancreatic enzymes are important components of evaluation, they cannot definitively diagnose the underlying pathology causing RUQ pain. 2, 3
• Blood work alone has insufficient sensitivity and specificity to rule out significant intra-abdominal pathology, including delayed presentations of traumatic injuries. 5

Critical Considerations in Post-Trauma RUQ Pain

• Delayed presentations of traumatic diaphragmatic hernia or other occult injuries can occur weeks to months after blunt abdominal trauma, even in patients who were initially stable. 5
• Ultrasound serves as an excellent screening tool to identify free fluid, solid organ injury, or other abnormalities that may represent delayed complications of trauma. 3
• If ultrasound findings are equivocal or suggest complications, CT abdomen with IV contrast should be the next step for comprehensive evaluation. 1, 3

Algorithmic Approach

1. Order abdominal ultrasound immediately as first-line imaging for RUQ pain evaluation. 1, 2, 3
2. Obtain concurrent laboratory testing including CBC, liver function tests (ALT, AST, alkaline phosphatase, bilirubin), and pancreatic enzymes (amylase, lipase). 2, 3
3. If ultrasound is diagnostic (e.g., acute cholecystitis, liver pathology), initiate appropriate treatment. 1
4. If ultrasound is negative or equivocal, proceed to CT abdomen with IV contrast to evaluate for traumatic complications or other pathology. 1, 3
5. Consider MRI with MRCP if biliary pathology is suspected but ultrasound and CT remain inconclusive. 1, 3

Common Pitfalls to Avoid

• Do not skip ultrasound and proceed directly to CT, as ultrasound provides rapid diagnosis and avoids unnecessary radiation exposure in stable patients. 1
• Do not dismiss mild symptoms in post-trauma patients, as serious injuries like diaphragmatic hernia can present with delayed, subtle symptoms. 5
• Do not order CT without IV contrast if you proceed to CT, as important findings like wall enhancement and organ perfusion cannot be detected without contrast. 1
• Do not rely solely on clinical examination or laboratory values to exclude significant pathology, as imaging is essential for definitive diagnosis. 2, 6