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

Initial Management: Abdominal Ultrasound

For a vitally stable patient presenting with mild right upper quadrant pain one week after a road traffic accident, perform an abdominal ultrasound immediately as the first-line diagnostic test. 1

Rationale for Ultrasound as Initial Step

• The American Academy of Family Physicians recommends obtaining an abdominal ultrasound immediately as the first-line imaging study for any patient presenting with right upper quadrant pain, regardless of etiology 1

• Ultrasound provides 96% accuracy for diagnosing intra-abdominal pathology in the RUQ and should be performed first in all patients with RUQ pain 1

• In the trauma context, ultrasound can identify delayed complications from blunt abdominal trauma including hepatic injuries, splenic injuries, and biliary pathology that may present days to weeks after the initial accident 2, 3

Why Not Emergency Department Referral?

• Emergency department referral is not indicated because the patient is vitally stable with no signs of acute deterioration 4

• Immediate referral to the emergency department is reserved for patients with fever and leukocytosis suggesting acute cholecystitis or cholangitis, or signs of peritonitis 4

• The one-week delay between trauma and presentation with mild symptoms suggests a subacute process rather than an acute emergency requiring immediate surgical evaluation 2

Why Not Blood Work First?

• Laboratory testing alone (CBC, liver enzymes) cannot definitively diagnose the cause of RUQ pain and should be performed concurrently with, not instead of, ultrasound 1

• While blood work can assess for leukocytosis and elevated liver enzymes, imaging is essential to identify structural abnormalities from trauma such as hepatic hematoma, splenic injury, or biliary complications 1, 3

• In post-traumatic RUQ pain, ultrasound provides direct visualization of solid organ injuries that blood work cannot detect 3

Trauma-Specific Considerations

• Road traffic accidents commonly cause abdominopelvic injuries affecting the liver, spleen, and kidney, with solid organ injuries being most frequent 2

• Delayed presentation of abdominal pain after trauma can indicate evolving hepatic hematoma, subcapsular splenic hematoma, or biliary injury that requires imaging diagnosis 2, 3

• Ultrasound can identify hepatic injuries, pericholecystic fluid, gallbladder wall abnormalities, and free fluid that may represent delayed bleeding or bile leak 1, 3

Algorithmic Approach After Initial Ultrasound

• If ultrasound is equivocal or nondiagnostic, proceed to CT abdomen with IV contrast to evaluate for complications and alternative diagnoses 1

• If ultrasound shows specific biliary pathology but further characterization is needed, consider MRCP which has 85-100% sensitivity for biliary abnormalities 4

• Complete blood count and liver function tests should be obtained alongside ultrasound to assess for leukocytosis and hepatobiliary enzyme elevation 1

Common Pitfalls to Avoid

• Do not skip ultrasound and proceed directly to CT, as ultrasound provides rapid, cost-effective diagnosis and avoids radiation exposure 1

• Do not order CT without IV contrast if CT is ultimately needed, as important findings like wall enhancement and liver hyperemia cannot be detected without contrast 1, 4

• Do not assume that vital stability one week post-trauma excludes significant intra-abdominal pathology, as delayed presentations of solid organ injuries are well-documented 2