What is the appropriate evaluation and management for a 64-year-old male presenting with abdominal pain on palpation in the Left Upper Quadrant (LUQ) and mild pulsatile pain?

Evaluation and Management of LUQ Pain with Pulsatile Character in a 64-Year-Old Male

This patient requires urgent CT angiography of the abdomen and pelvis with IV contrast to evaluate for abdominal aortic aneurysm (AAA) or splenic artery aneurysm, as pulsatile pain in the left upper quadrant is a red flag for vascular pathology that can be life-threatening if ruptured.

Immediate Clinical Assessment

The combination of pulsatile pain and left upper quadrant tenderness in a 64-year-old male mandates immediate consideration of vascular emergencies:

• Pulsatile quality is the critical distinguishing feature that elevates concern for AAA, splenic artery aneurysm, or other vascular pathology requiring emergent imaging 1
• Check vital signs immediately for hemodynamic instability (hypotension, tachycardia) which would indicate possible rupture requiring emergency surgery 1
• Palpate for a pulsatile abdominal mass, though absence does not exclude AAA, particularly in obese patients 1
• Assess for signs of peritonitis (guarding, rebound tenderness, rigidity) which would suggest rupture or perforation 2

Imaging Strategy

CT angiography with IV contrast is the definitive imaging modality for evaluating pulsatile abdominal pain:

• CT with IV contrast provides comprehensive evaluation of vascular structures, aneurysm size, and evidence of rupture or leak 3
• The American College of Radiology recommends CT abdomen and pelvis with IV contrast as the preferred imaging for acute nonlocalized abdominal pain, rating it 8/9 (usually appropriate) 2, 4
• Do not delay imaging with plain radiography, as it has no role in evaluating acute abdominal pain and will only delay definitive diagnosis 5
• Ultrasonography is operator-dependent and may miss vascular pathology in the setting of bowel gas or patient body habitus 3

Differential Diagnosis for LUQ Pulsatile Pain

While vascular pathology is the primary concern, consider:

• Abdominal aortic aneurysm (most critical diagnosis to exclude given pulsatile nature and age) 1
• Splenic artery aneurysm (third most common intra-abdominal aneurysm, can present with LUQ pain) 1
• Pancreatitis (though typically epigastric, can radiate to LUQ; less likely to be pulsatile) 3
• Splenic infarction or rupture (would show on CT with contrast) 3
• Gastric pathology including perforation (CT would identify free air) 3
• Renal artery dissection (can present with flank/abdominal pain, though more commonly lower quadrant) 6

Laboratory Workup

While imaging should not be delayed, obtain:

• Complete blood count (assess for anemia from bleeding, leukocytosis from infection/inflammation) 1
• Lipase (evaluate for pancreatitis) 1
• Hepatobiliary markers (ALT, AST, bilirubin, alkaline phosphatase) 1
• Lactate (elevated in mesenteric ischemia or sepsis) 3
• Type and screen (prepare for potential surgical intervention) 1

Critical Management Decisions

If AAA is confirmed on imaging:

• Aneurysms ≥5.5 cm or symptomatic aneurysms of any size require urgent vascular surgery consultation 1
• Contained rupture requires emergent surgical repair 1
• Hemodynamically unstable patients require immediate operative intervention 1

If imaging excludes vascular pathology:

• CT will identify alternative diagnoses such as pancreatitis, splenic pathology, gastric perforation, or nephrolithiasis 3
• Management then follows diagnosis-specific protocols 3

Common Pitfalls to Avoid

• Never attribute pulsatile abdominal pain to benign causes without imaging - this is a vascular emergency until proven otherwise 1
• Do not rely on physical examination alone; AAA can be missed clinically, especially in obese patients 1
• Avoid ordering plain radiography as it provides no useful information and delays definitive diagnosis 5
• Do not start with ultrasonography for pulsatile pain; CT angiography is required for adequate vascular assessment 3
• In elderly patients, typical signs of serious pathology may be masked despite life-threatening conditions 3