What is the most appropriate next step for a vitally stable patient with mild right upper quadrant abdominal pain 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 a recent road traffic accident, order an abdominal ultrasound immediately to evaluate for delayed traumatic complications, particularly hepatobiliary injury. 1

Rationale for Ultrasound as First-Line Imaging

• The American College of Radiology rates ultrasound 9/9 (usually appropriate) as the first-line diagnostic test for right upper quadrant pain evaluation in patients with mild symptoms one week after a road traffic accident. 1

• Ultrasound is ideal for detecting delayed hepatic injuries, such as subcapsular hematomas and lacerations, in patients with a history of trauma. 1

• Ultrasound can detect biliary complications from trauma, including hemobilia, bile duct injury, and biloma, in patients presenting with right upper quadrant pain. 1

• Ultrasound provides rapid, cost-effective diagnosis without radiation exposure, making it superior to CT for initial evaluation in stable patients. 1

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

• Ordering ultrasound in the clinic setting allows for appropriate diagnostic evaluation without unnecessary emergency department utilization. 1

• Emergency referral should be reserved for hemodynamically unstable patients or those with peritoneal signs suggesting acute surgical abdomen. 1

Why Not Blood Work Alone?

• Many traumatic injuries require imaging for diagnosis, and laboratory values alone are insufficient to rule out significant hepatobiliary injury. 1

• The American College of Radiology recommends not skipping imaging and relying solely on clinical examination or laboratory values. 1

• However, concurrent laboratory studies including complete blood count and liver function tests should be obtained alongside ultrasound to assess for anemia, leukocytosis, and hepatobiliary injury. 1

Critical Clinical Algorithm

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

• Obtain concurrent laboratory studies including complete blood count and liver function tests while awaiting ultrasound results. 1

• If ultrasound is negative or equivocal and clinical suspicion remains high for traumatic injury, proceed to CT abdomen/pelvis with IV contrast for comprehensive evaluation of solid organ injuries, bowel injuries, and vascular complications. 1

• If ultrasound demonstrates biliary pathology requiring further characterization, proceed to MRCP, which provides 85-100% sensitivity and 90% specificity for biliary tree evaluation. 1

Avoiding Critical Pitfalls

• Do not dismiss mild symptoms in the setting of recent trauma, as delayed presentations of blunt abdominal trauma can be life-threatening, including strangulated diaphragmatic herniae and evolving hepatic injuries. 1

• Do not skip imaging based on vital stability alone—imaging evaluation is mandatory even with mild symptoms following trauma. 1

• Consider traumatic appendicitis in the differential diagnosis, as blunt abdominal trauma can rarely cause acute appendicitis through direct compression, shearing injury, or indirect obstruction of the appendiceal lumen. 2, 3

• Maintain high index of suspicion for hollow viscus injury, which can be missed on initial evaluation and lead to delayed peritonitis and death if not properly diagnosed. 4