What is the most appropriate next step in managing a vitally stable patient with mild right upper quadrant abdominal pain following a recent road traffic accident?

Abdominal Ultrasound is the Most Appropriate Next Step

For a vitally stable patient with mild right upper quadrant pain following a recent road traffic accident, perform an abdominal ultrasound immediately as the first-line diagnostic test. 1, 2

Rationale for Ultrasound as Initial Management

• The American College of Radiology rates ultrasound 9/9 (usually appropriate) for hemodynamically stable patients with right upper quadrant pain, including those in the post-traumatic setting. 1

• Ultrasound achieves 96% accuracy for detecting gallstones and biliary pathology, which are the most common causes of RUQ pain, even in patients presenting one week after trauma. 1

• In the post-traumatic context, ultrasound is ideal for detecting delayed hepatic injuries (subcapsular hematomas, lacerations), biliary complications (hemobilia, bile duct injury, biloma), and free fluid suggesting hemorrhage. 2

• Ultrasound is rapid, cost-effective, radiation-free, and can identify multiple pathologies including gallbladder wall thickening, pericholecystic fluid, hepatic injuries, and other organ abnormalities. 1, 3

Why Not Emergency Department Referral?

• The American College of Radiology specifies that immediate ED referral is indicated for fever with leukocytosis, hemodynamic instability, or peritoneal signs—none of which are present in this vitally stable patient with only mild pain. 1

• The delayed presentation (one week post-RTA) with mild symptoms suggests lower likelihood of acute hemorrhage or visceral perforation, making outpatient diagnostic workup with ultrasound appropriate. 1

• The American College of Emergency Physicians emphasizes not dismissing mild symptoms in recent trauma, but this mandates imaging evaluation (ultrasound), not automatic ED referral. 2

Why Not Blood Work Alone?

• Laboratory testing (CBC, liver function tests, pancreatic enzymes) should be obtained concurrently or immediately after ultrasound, not as a standalone initial step. 1

• Many traumatic injuries require imaging for diagnosis—clinical examination and laboratory values alone are insufficient, as ultrasound provides rapid, cost-effective diagnosis without radiation exposure. 2

• Elevated liver enzymes suggest hepatobiliary disease and elevated amylase/lipase suggest pancreatitis, but these findings require anatomic correlation with imaging to guide management. 1

Clinical Algorithm

1. Order right upper quadrant ultrasound immediately to evaluate for hepatic injury, biliary pathology, and free fluid. 2

2. Obtain concurrent laboratory studies including CBC and liver function tests to assess for anemia, leukocytosis, and hepatobiliary injury. 2

3. If ultrasound is negative or equivocal and clinical suspicion remains high, proceed to CT abdomen/pelvis with IV contrast for comprehensive evaluation of solid organ injuries, bowel injuries, and vascular complications. 2

4. If ultrasound shows concerning findings such as acute cholecystitis features (wall thickening, pericholecystic fluid, positive sonographic Murphy's sign), arrange surgical consultation. 1

5. If hepatic injury or free fluid is detected, CT may be required for further characterization. 1

Critical Pitfalls to Avoid

• Do not skip imaging based solely on vital stability and mild symptoms—delayed presentations of blunt abdominal trauma can be life-threatening, including strangulated diaphragmatic herniae and evolving hepatic injuries. 2

• Do not order CT without prior ultrasound—CT exposes the patient to unnecessary radiation and has only 75% sensitivity for gallstones compared to ultrasound's 96% accuracy. 1

• Do not rely on clinical examination alone—ultrasound is the study of choice for right upper quadrant pain and should be performed even in stable patients with mild symptoms following trauma. 4, 3