Left upper quadrant abdominal pain

Background

• This page outlines the general approach to adult left upper quadrant (LUQ) pain
• LUQ contains: spleen, stomach, left kidney, splenic flexure of colon, tail of pancreas, and left adrenal gland
• Key EM considerations: splenic pathology (rupture, infarct, abscess), gastric/peptic ulcer disease, pancreatitis, renal pathology
• Remember referred pain sources: left lower lobe pneumonia, MI, pericarditis

Classification by Abdominal pain location

Side-by-side comparison of quadrants and regions.

Chart of commonly reported referred pain sites.

RUQ pain	Epigastric pain	LUQ pain
Flank pain	Diffuse abdominal pain	Flank pain
RLQ pain	Pelvic pain	LLQ pain

Clinical Features

History

• Onset, character, radiation, timing, severity
• Associated symptoms: nausea/vomiting, fever, hematochezia/melena, pleuritic chest pain
• Recent trauma (splenic injury)
• History of blood dyscrasias, anticoagulation, mononucleosis (splenic enlargement)
• Alcohol use, gallstones (pancreatitis)
• NSAID use, H. pylori history (peptic ulcer disease)
• History of atrial fibrillation or hypercoagulable state (splenic infarct)

Physical Exam

• LUQ tenderness, guarding, peritoneal signs
• Kehr sign: left shoulder pain from diaphragmatic irritation (splenic injury, ruptured spleen)
• Splenomegaly
• Epigastric tenderness radiating to back (pancreatitis)
• CVA tenderness (pyelonephritis, nephrolithiasis)

Red Flags

• Hemodynamic instability with LUQ pain (splenic rupture, ruptured AAA)
• Kehr sign (hemoperitoneum)
• Recent trauma + LUQ pain (delayed splenic rupture can occur weeks after injury)
• LUQ pain + atrial fibrillation (splenic artery embolism/infarct)

Differential Diagnosis

Left upper quadrant abdominal pain

• GERD
• Peptic ulcer disease with or without perforation
• Pancreatitis
• Splenic infarction/Splenic artery aneurysm rupture
• Pyelonephritis
• Bowel obstruction
• Myocardial Ischemia
• Pneumonia
• Pulmonary embolism
• Herpes zoster
• Pericarditis/Myocarditis
• Aortic Dissection

Must Not Miss

• Splenic rupture (traumatic or spontaneous)
• Splenic infarct (embolic, sickle cell crisis)
• Myocardial infarction (referred pain — always consider in older patients)
• Left lower lobe pneumonia (referred to LUQ)

Evaluation

Laboratory

• CBC, BMP
• LFTs, lipase
• Urinalysis
• Urine pregnancy test (females of reproductive age)
• Lactate if concern for mesenteric ischemia or sepsis
• Troponin, ECG if cardiac cause considered (age >40 or risk factors)
• Coagulation studies if anticoagulated or concern for splenic hemorrhage

Imaging

• CT abdomen pelvis with IV contrast: most useful for LUQ pathology (splenic infarct, abscess, mass, pancreatitis, renal pathology)
• POCUS/FAST exam: evaluate for free fluid (splenic rupture)
• CXR: if concern for pneumonia or free air (perforated ulcer)
• RUQ US: if concern for biliary/hepatic pathology

Management

• Treat underlying disease process
• IV fluids and analgesia
• Consider GI cocktail if gastritis/peptic ulcer suspected
• Emergent surgical consultation for splenic rupture
• Hematology consultation for splenic infarction

Disposition

• Based on underlying diagnosis
• Admit: splenic pathology, pancreatitis requiring IV management, mesenteric ischemia, MI
• Discharge: mild gastritis, stable renal colic, musculoskeletal pain with clear follow-up

See Also

• Abdominal Pain
• Abdominal Pain (Peds)