What is the appropriate evaluation and management for left upper quadrant (LUQ) pain on palpation?

Evaluation and Management of Left Upper Quadrant (LUQ) Pain on Palpation

For acute left upper quadrant pain on palpation, obtain CT abdomen and pelvis with IV contrast as the first-line imaging study, along with comprehensive laboratory workup including CBC, liver enzymes, amylase/lipase, and pregnancy test in women of reproductive age. 1

Initial Laboratory Assessment

Order the following tests immediately for all patients presenting with LUQ pain on palpation:

• Complete blood count (CBC) to assess for leukocytosis suggesting infection, inflammation, or splenic pathology 2
• Comprehensive metabolic panel including liver function tests (ALT, AST, alkaline phosphatase, bilirubin) to evaluate hepatobiliary disease 2
• Pancreatic enzymes (amylase and lipase) as pancreatitis is a common cause of LUQ pain; elevated levels strongly suggest this diagnosis 2
• Pregnancy test for all women of reproductive age to exclude ectopic pregnancy or pregnancy-related complications 2
• Renal function tests (BUN, creatinine) to assess kidney pathology 2

Additional Laboratory Tests Based on Clinical Suspicion

• Coagulation studies (PT/INR, PTT) if splenic rupture or hematoma is suspected 2
• Lactate level if mesenteric ischemia or severe infection is suspected 2
• Urinalysis to evaluate for renal stones or urinary tract infection 2

Critical caveat: Normal laboratory values do not exclude serious pathology; imaging remains necessary based on clinical presentation. 2

Imaging Strategy

First-Line Imaging

CT abdomen and pelvis with IV contrast is the gold standard initial imaging modality for LUQ pain due to its superior diagnostic accuracy and ability to detect a wide range of pathologies. 1 This recommendation comes from the American College of Radiology and is based on CT's ability to:

• Change the leading diagnosis in up to 51% of patients 1
• Alter management decisions in 25% of patients with abdominal pain 1
• Provide comprehensive evaluation of splenic, pancreatic, gastric, renal, and colonic pathology 1

IV contrast enhancement is essential as it improves detection of bowel wall pathology, vascular abnormalities, and intraabdominal fluid collections. 1

Alternative Imaging Approaches

Use ultrasound as initial imaging in these specific scenarios:

• Pregnant patients or young patients where radiation exposure is a concern 1
• Premenopausal women when gynecologic pathology is suspected 1
• When IV contrast is contraindicated, proceed with unenhanced CT 1

Imaging to Avoid

• Plain radiography has limited utility for LUQ pain due to low sensitivity, though it may detect pneumoperitoneum or bowel obstruction 1
• MRI is not recommended for initial evaluation due to longer acquisition time, less sensitivity for extraluminal air, and motion artifacts in symptomatic patients 1

Common Pathologies to Consider

Splenic Pathology

• Splenic infarction, abscess, or rupture
• Splenic torsion (look for "upside down spleen" sign on coronal CT reconstruction) 3
• Intrasplenic pseudocysts from pancreatitis 4

Pancreatic Pathology

• Acute pancreatitis requires contrast-enhanced CT for severity assessment and detection of complications 1
• Pancreatic tail pseudocysts may present with LUQ pain 4

Renal Pathology

• Pyelonephritis or nephrolithiasis (unenhanced CT has near 100% sensitivity and specificity for stones) 1

Gastrointestinal Pathology

• Colitis or diverticulitis extending to the LUQ can be evaluated with high accuracy on CT 1
• Rare presentations include appendicitis in patients with intestinal malrotation 5
• Internal hernias through the foramen of Winslow 6

Management Based on CT Findings

If CT Confirms Colitis

Review CT carefully for complications requiring urgent intervention: perforation, abscess formation, bowel obstruction, or toxic megacolon. 7

Assess for surgical abdomen: fever with inability to pass gas/stool, severe tenderness with guarding, vomiting, bloody stools, or signs of shock mandate immediate surgical consultation. 7

Most uncomplicated diverticulitis can be managed with outpatient antibiotics. 7 Colonic wall thickness <9 mm predicts lower recurrence risk (19%). 7

Red Flags Requiring Urgent Surgical Consultation

• Pericolonic lymphadenopathy >1 cm suggests malignancy rather than benign inflammatory process and requires colonoscopy with biopsy 7
• Free perforation or large abscess requires surgical consultation 7
• Signs of toxic megacolon or severe ischemic colitis with peritonitis 7

Clinical Pearls

• CT sensitivity for acute abdominal abnormalities in LUQ pain is 69% with excellent specificity of 100% 8
• Elevated white blood cell count with left shift suggests infection or inflammation, potentially indicating splenic abscess, pancreatitis, or diverticulitis 2
• Consider age, sex, and clinical presentation when selecting imaging modality 1
• Acute appendicitis should be in the differential for LUQ pain, particularly in patients with intestinal malrotation 5

Common Pitfalls to Avoid

• Failing to order pregnancy test in women of reproductive age, potentially missing ectopic pregnancy 2
• Relying solely on plain radiographs which have poor sensitivity for most causes of LUQ pain 1
• Failing to use contrast enhancement when evaluating for vascular pathologies or abscesses 1
• Delaying appropriate imaging in elderly patients who may present with atypical symptoms and normal laboratory values 1
• Relying solely on laboratory tests without appropriate imaging studies when clinically indicated 2