What is the appropriate management for left upper quadrant abdominal pain persisting for 3 days?

Management of Left Upper Quadrant Abdominal Pain

CT scan with IV contrast is the most appropriate initial diagnostic test for persistent left upper quadrant (LUQ) pain. 1, 2

Diagnostic Approach

Initial Evaluation

• LUQ pain differs from the more common left lower quadrant (LLQ) pain which is typically associated with diverticulitis
• Differential diagnosis for LUQ pain includes:
  • Splenic disorders (infarction, abscess, rupture)
  • Gastric pathology (gastritis, peptic ulcer)
  • Pancreatic disease (pancreatitis)
  • Left-sided colonic issues (diverticulitis extending to LUQ)
  • Renal pathology (pyelonephritis, nephrolithiasis)
  • Vascular issues (mesenteric ischemia)

Imaging Selection

• CT abdomen and pelvis with IV contrast is the first-line imaging study 1, 2

  • Highly sensitive for detecting inflammatory conditions, vascular pathologies, and solid organ abnormalities
  • Can identify small quantities of extraluminal air indicating perforation
  • Provides comprehensive assessment of all potential causes in the LUQ

• Ultrasound may be considered in specific situations:

  • When radiation exposure is a concern
  • As an initial screening tool for splenic or renal pathology
  • In pregnant patients where radiation should be avoided

Management Algorithm

1. Assess severity and stability:

   • If hemodynamically unstable: immediate surgical consultation and resuscitation
   • If stable: proceed with diagnostic workup

2. Obtain CT scan with IV contrast:

   • Provides comprehensive evaluation of all potential causes 1
   • Superior to plain radiography which has limited utility 1

3. Based on CT findings:

   If splenic pathology:

   • Splenic infarction: anticoagulation if embolic source identified
   • Splenic abscess: antibiotics and possible drainage
   • Splenic rupture: surgical consultation for possible splenectomy

   If gastric pathology:

   • Gastritis/PUD: PPI therapy, H. pylori testing and treatment if positive
   • Perforation: surgical consultation

   If pancreatic disease:

   • Acute pancreatitis: bowel rest, IV fluids, pain management
   • Pancreatic abscess/pseudocyst: possible drainage

   If colonic pathology:

   • Diverticulitis: antibiotics (amoxicillin-clavulanate 875/125 mg twice daily for 4-7 days) 2

   If renal pathology:

   • Pyelonephritis: appropriate antibiotics
   • Nephrolithiasis: pain management, hydration

Special Considerations

• MRI is generally not recommended as first-line for acute LUQ pain as it is:

  • Less sensitive for extraluminal air
  • More time-consuming
  • Subject to motion artifacts in symptomatic patients 1

• Plain radiography has limited utility in LUQ pain evaluation as it can only detect large amounts of free air or significant bowel obstruction 1

• If no clear diagnosis is found on initial imaging but symptoms persist, consider:

  • Consultation with gastroenterology
  • Endoscopic evaluation
  • Follow-up imaging in 48-72 hours if symptoms worsen 2

Common Pitfalls to Avoid

• Assuming LUQ pain is always related to splenic pathology
• Failing to consider vascular causes like mesenteric ischemia in elderly patients
• Overlooking referred pain from thoracic pathology (pneumonia, pulmonary embolism)
• Delaying imaging in patients with persistent pain despite normal laboratory values

CT with IV contrast remains the cornerstone of diagnosis for LUQ pain, with management directed by the specific pathology identified 1, 2.