What is the most appropriate next step for a patient with epigastric pain, nausea, vomiting, upper abdominal distention, and bruises after a recent fall from a bicycle?

Abdominal CT is the Most Appropriate Next Step

This patient requires immediate abdominal CT imaging to evaluate for delayed traumatic injury, specifically pancreatic or duodenal injury, which commonly presents with delayed symptoms 1-3 weeks after blunt abdominal trauma. 1

Clinical Reasoning

The combination of findings creates a high-risk scenario that demands urgent imaging:

• Delayed presentation after trauma: Epigastric pain developing 2-3 weeks after bicycle fall is classic for pancreatic injury, duodenal hematoma, or traumatic pancreatitis 1
• Upper abdominal distention with bruising: Suggests ongoing intra-abdominal pathology, not simple gastroenteritis 1
• Nausea and vomiting: Consistent with either pancreatic inflammation or duodenal obstruction from hematoma 1

Why CT Over Other Options

Contrast-enhanced abdominal CT provides 98% sensitivity and 98% specificity for solid organ injuries, and 85% sensitivity with 96% specificity for hollow organ injuries in blunt abdominal trauma. 1 The diagnostic performance far exceeds ultrasound for this clinical scenario.

CT is Superior Because:

• Detects pancreatic injuries: CT identifies pancreatic lacerations, pseudocysts, and traumatic pancreatitis that ultrasound frequently misses 1
• Evaluates the retroperitoneum: Duodenal hematomas and retroperitoneal bleeding are not visible on ultrasound 1
• Identifies complications: CT detects bowel perforation, abscess formation, and mesenteric injuries 1
• Guides management: CT findings determine whether conservative management, interventional radiology, or surgery is needed 1

Why NOT Ultrasound (Option D):

Ultrasound has only 56-71% sensitivity for detecting intra-abdominal injuries in blunt trauma and cannot reliably exclude retroperitoneal pathology. 1 A negative ultrasound does not rule out pancreatic injury, duodenal hematoma, or retroperitoneal bleeding—the exact injuries this patient is at risk for. 1

Why NOT Observation (Option A):

Observation without imaging in a patient with persistent symptoms weeks after trauma risks missing life-threatening complications. 1 Delayed presentations of pancreatic injuries can progress to infected pseudocysts, abscess formation, or hemorrhage. 1 The European guidelines explicitly state that hemodynamically stable patients with suspected abdominal trauma require CT imaging, not observation alone. 1

Why NOT Laparoscopy (Option C):

Laparoscopy is invasive and unnecessary when non-invasive CT imaging can establish the diagnosis with >90% accuracy. 1 Laparoscopy is reserved for patients with equivocal imaging findings or those requiring therapeutic intervention, not as a first-line diagnostic tool. 1

Critical Pitfalls to Avoid

• Do not rely on hemodynamic stability to exclude serious injury: Pancreatic injuries and duodenal hematomas can remain hemodynamically stable for weeks before decompensating 1
• Do not dismiss delayed presentations: Traumatic pancreatic and duodenal injuries characteristically present 1-3 weeks after the initial trauma 1
• Do not use ultrasound as definitive imaging: Ultrasound cannot adequately evaluate the pancreas or retroperitoneum in this clinical context 1

Immediate Management Algorithm

1. Order contrast-enhanced abdominal and pelvic CT immediately 1
2. Ensure IV access and NPO status while awaiting imaging 1
3. Based on CT findings:
   • If pancreatic injury or pseudocyst: Surgical consultation, NPO, IV fluids, pain control 1
   • If duodenal hematoma: Surgical consultation, consider nasogastric decompression 1
   • If free fluid with any hemodynamic change: Immediate surgical intervention 1
   • If negative CT: Consider alternative diagnoses (gastritis, peptic ulcer) 1

The mortality risk increases approximately 1% every 3 minutes when significant internal hemorrhage goes uncontrolled, making timely diagnosis with CT imaging essential. 2