Initial Management of Post-Traumatic Right Upper Quadrant Pain
Perform an abdominal ultrasound immediately as the first-line diagnostic test for this patient with mild right upper quadrant pain one week after a road traffic accident. 1, 2, 3
Rationale for Ultrasound as Initial Step
The American Academy of Family Physicians and American College of Radiology both recommend ultrasound as the primary imaging modality for any patient presenting with right upper quadrant pain, rating it 9/9 (usually appropriate). 1, 2 This applies even in the post-traumatic setting when the patient is hemodynamically stable. 1
Key advantages of ultrasound in this clinical scenario:
- 96% accuracy for detecting gallstones and biliary pathology, which are the most common causes of RUQ pain 1, 2
- Rapid, cost-effective, and radiation-free evaluation 1, 4
- Can identify multiple pathologies including gallbladder wall thickening, pericholecystic fluid, hepatic injuries, and other organ abnormalities 1, 2
- Dynamic examination that allows real-time assessment including Murphy's sign 4
Why Not Emergency Department Referral?
This patient is vitally stable with only mild pain one week post-trauma, which does not meet criteria for urgent ED referral. 1 The American College of Radiology guidelines specify that immediate ED referral is indicated for fever with leukocytosis suggesting acute cholecystitis or cholangitis, hemodynamic instability, or peritoneal signs—none of which are present in this case. 1, 5
The delayed presentation (1 week post-RTA) with mild symptoms suggests:
- Lower likelihood of acute hemorrhage or visceral perforation
- More likely biliary pathology, hepatic contusion, or other subacute processes
- Appropriate for outpatient diagnostic workup starting with ultrasound 1, 2
Why Not Blood Work First?
While laboratory testing including complete blood count, liver function tests, and pancreatic enzymes is recommended as part of the evaluation, imaging should not be delayed to obtain these results in a stable patient with RUQ pain. 1, 2 The ultrasound can be performed immediately and provides more definitive diagnostic information than laboratory values alone. 1
Laboratory testing should be obtained concurrently or immediately after ultrasound to assess for:
- Leukocytosis indicating infection or inflammation 2
- Elevated liver enzymes (ALT, AST, alkaline phosphatase, bilirubin) suggesting hepatobiliary disease 2
- Elevated amylase/lipase if pancreatitis is suspected 2
Critical Pitfall to Avoid
Do not skip ultrasound and proceed directly to CT, even in the trauma setting, unless the patient is hemodynamically unstable. 1, 5 CT without prior ultrasound exposes the patient to unnecessary radiation and has only 75% sensitivity for gallstones compared to ultrasound's 96% accuracy. 1, 5
Next Steps After Ultrasound
If ultrasound is equivocal or nondiagnostic:
- Proceed to CT abdomen with IV contrast to evaluate for complications such as perforation, hemorrhage, or adjacent liver parenchymal injury 6, 1
- CT without IV contrast misses critical findings like gallbladder wall enhancement and liver hyperemia 1, 5
If ultrasound shows concerning findings: