When managing suspected abdominal bleeding with referred shoulder pain, which organ injury is most likely?

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Referred shoulder pain from abdominal bleeding comes from irritation of the diaphragm by blood in the peritoneal cavity. The liver lies directly under the right hemidiaphragm and is large and highly vascular, so injuries to the liver commonly spill blood into the peritoneum and irritate the diaphragmatic surface. That irritation sends pain up to the shoulder via the phrenic nerve, making liver injury the most likely explanation when there’s suspected abdominal bleeding with shoulder pain.

Pancreas and kidneys sit behind the peritoneum (retroperitoneal), so bleeding there tends to cause back or flank pain rather than shoulder pain. The spleen can cause left shoulder pain (Kehr sign) with diaphragmatic irritation, but the pattern described here most consistently points to liver injury under the right diaphragm.