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
| 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