Is an immediate abdominal ultrasound, administration of normal saline, and glucose support appropriate for a patient with left upper quadrant pain, a palpable lump, and hypotension?

Management of Left Upper Quadrant Pain with Hypotension

For a patient with left upper quadrant pain, a palpable lump, and hypotension (99/66 mmHg), an immediate abdominal ultrasound is appropriate, along with fluid resuscitation using normal saline to support blood pressure. 1

Initial Assessment and Management

• Bedside ultrasonography is the first-line imaging modality for evaluating a hypotensive patient with left upper quadrant pain and a palpable mass, as it can rapidly identify free fluid suggesting intraabdominal bleeding 1
• Immediate fluid resuscitation with normal saline should be initiated to address hypotension, which at 99/66 mmHg suggests potential hemodynamic compromise 1
• Laboratory tests should include complete blood count, liver function tests, pancreatic enzymes, and renal function tests to evaluate for splenic, pancreatic, or other pathology 2

Rationale for Ultrasound as First-Line Imaging

• Ultrasound has several advantages in this clinical scenario:

  • Rapid bedside availability without moving a potentially unstable patient 1
  • No radiation exposure 1
  • Can identify free fluid in the abdomen with sensitivity of 79-100% and specificity of 94-100% in hypotensive trauma patients 1
  • Can visualize the spleen, a common source of left upper quadrant pathology 2, 3

• For left upper quadrant pain with a palpable mass, ultrasound can detect:

  • Splenic enlargement or rupture 2
  • Perisplenic fluid collections 1
  • Abscesses or hematomas 1, 2

Fluid Resuscitation Protocol

• Begin with normal saline bolus (1-2 L) for a hypotensive patient 1
• Target systolic blood pressure >90 mmHg to maintain adequate organ perfusion 1
• Monitor response to fluid resuscitation; inadequate response may indicate ongoing bleeding requiring surgical intervention 1

Follow-up Imaging Considerations

• If ultrasound is negative but clinical suspicion remains high, or if the patient remains unstable despite initial management:
  • CT with IV contrast is indicated as the next imaging step 1, 3
  • CT has superior sensitivity (69%) and excellent specificity (100%) for identifying causes of left upper quadrant pain 3

Common Pitfalls to Avoid

• Relying solely on a single ultrasound examination, as fluid takes time to accumulate; serial ultrasounds may be necessary 1
• Failing to recognize that a negative ultrasound does not exclude serious pathology in a hypotensive patient with left upper quadrant pain 1, 2
• Delaying fluid resuscitation while waiting for diagnostic studies 1
• Using CT as first-line imaging in an unstable patient, as this delays resuscitation and may require patient transport 1

Special Considerations

• If splenic injury is suspected based on ultrasound findings, immediate surgical consultation is warranted 1, 2
• For female patients of reproductive age, include a pregnancy test to rule out ectopic pregnancy 2, 4
• Consider coagulation studies if splenic rupture or hematoma is suspected 2