What is the diagnosis and treatment for a patient with a click felt during deep palpation in the left upper quadrant?

Diagnosis and Management of a Click Felt During Deep Palpation in the Left Upper Quadrant

Most Likely Diagnosis

A palpable click in the left upper quadrant during deep palpation most likely represents an abdominal finding unrelated to cardiac pathology, and requires imaging with CT to identify splenic, pancreatic, gastric, or renal pathology as the source of symptoms. 1

Critical Distinction: Cardiac vs. Abdominal Click

The term "click" in medical terminology typically refers to a cardiac auscultatory finding (midsystolic click heard with a stethoscope), not a palpable tactile sensation. 2 However, since the question specifically states this is felt during deep palpation of the left upper quadrant, this represents an abdominal examination finding, not a cardiac one.

Why This Matters for Diagnosis:

• Cardiac midsystolic clicks are high-pitched sounds heard on auscultation, not felt on palpation, and result from sudden tensing of the mitral valve apparatus during systole in mitral valve prolapse (MVP). 2
• Palpable sensations in the left upper quadrant during deep palpation suggest structural abdominal pathology requiring imaging evaluation. 1

Recommended Diagnostic Approach

Initial Imaging

CT of the abdomen is the recommended initial imaging test for evaluating left upper quadrant pain when the diagnosis is unclear from history and physical examination. 1

• CT can identify splenic pathology (infarction, rupture, abscess), pancreatic disease (pancreatitis, masses), gastric abnormalities, or renal pathology. 1
• MRI may be considered if CT results are equivocal. 1

Important Caveat About Fatty Liver

If imaging incidentally reveals fatty liver disease, recognize that fatty liver typically does not cause left upper quadrant pain, and other etiologies must still be pursued. 1

Differential Diagnosis for Left Upper Quadrant Findings

The left upper quadrant contains several organs that could produce palpable abnormalities:

• Splenic pathology: Splenomegaly, splenic infarction, or subcapsular hematoma
• Pancreatic disease: Pancreatitis (especially tail of pancreas), pancreatic masses, or pseudocysts
• Gastric abnormalities: Gastric distension or masses
• Renal pathology: Left kidney masses or hydronephrosis
• Colonic disease: Splenic flexure pathology (though less likely to produce a "click")

Special Consideration for Mesenteric Ischemia

If the palpable finding is associated with pain related to eating, consider mesenteric ischemia in the appropriate clinical context. 1

Management Based on CT Findings

Treatment should be directed at the specific pathology identified on imaging. 1

• Splenic pathology: May require surgical consultation depending on severity
• Pancreatitis: Supportive care, bowel rest, fluid resuscitation
• Masses: Further characterization and oncologic evaluation as appropriate
• Diverticulitis (if involving splenic flexure): Medical management or surgical intervention based on severity 2

When to Consider Cardiac Evaluation

Cardiac evaluation with echocardiography would only be indicated if the patient has:

• An audible midsystolic click on cardiac auscultation (not just a palpable sensation) 2
• Associated symptoms of palpitations, especially if accompanied by syncope, presyncope, or chest pain 3
• Physical examination findings suggestive of mitral valve prolapse 2

Echocardiography Indications for MVP

If cardiac MVP is suspected based on auscultatory findings, echocardiography is indicated for diagnosis and assessment of mitral regurgitation, leaflet morphology, and ventricular compensation in patients with physical signs of MVP. 2

Common Pitfalls to Avoid

• Do not confuse palpable abdominal findings with cardiac auscultatory findings. The term "click" in cardiology refers to a sound, not a tactile sensation. 2
• Do not attribute left upper quadrant symptoms to incidentally discovered fatty liver disease, as fatty liver does not cause localized abdominal pain. 1
• Do not delay imaging in patients with persistent or severe left upper quadrant symptoms, as serious pathology (splenic rupture, pancreatic necrosis) requires urgent intervention.

Follow-Up Recommendations

Follow-up should be based on the specific pathology identified on imaging. 1

• If no acute pathology is found and symptoms persist, consider gastroenterology referral for functional disorders
• Serial imaging may be warranted if initial studies are equivocal or symptoms progress