What are the possible causes and treatments for left upper quadrant pain and umbilical pain?

Left Upper Quadrant and Umbilical Pain: Diagnostic Approach and Management

Immediate Diagnostic Imaging

CT abdomen and pelvis with IV contrast is the first-line imaging modality for evaluating left upper quadrant (LUQ) and umbilical pain when the diagnosis is unclear, as it provides superior diagnostic accuracy and can detect the broad range of pathologies affecting these regions. 1, 2

• CT changes the leading diagnosis in up to 51% of patients and alters management decisions in 25% of cases with abdominal pain 1
• CT with IV contrast improves detection of bowel wall pathology, pericolic abnormalities, vascular pathology, and intraabdominal fluid collections 1

Critical Life-Threatening Conditions to Rule Out First

Before proceeding with systematic evaluation, immediately assess for conditions requiring emergent intervention:

• Mesenteric ischemia, perforated viscus, leaking abdominal aortic aneurysm, acute myocardial infarction, and ectopic pregnancy (in women of reproductive age) must be ruled out immediately 2
• Assess vital signs for signs of shock, which may indicate perforation, ischemia, or hemorrhage 2

Common Causes by Location

Left Upper Quadrant Pain

Splenic pathology (infarction, abscess, hematoma, rupture):

• Consider particularly in trauma or coagulopathy settings 2

Pancreatic disorders:

• Acute pancreatitis requires CT for severity assessment and detection of complications 1
• Chronic pancreatitis is the most common pancreatic cause of chronic LUQ pain 2

Gastric conditions:

• Gastritis, peptic ulcer disease, gastric outlet obstruction 2

Renal pathology:

• Pyelonephritis and nephrolithiasis can present with LUQ pain 1, 2
• Unenhanced CT has sensitivity and specificity near 100% for urolithiasis 1

Colonic disorders:

• Diverticulitis extending to the LUQ can be evaluated with CT 1

Atypical presentations:

• Appendicitis with intestinal malrotation can present as LUQ pain and should be considered in the differential 3
• Herpes zoster (shingles) can present as severe LUQ pain before vesicle eruption 4

Umbilical Pain

Early appendicitis:

• Periumbilical pain is a classic early presentation before migration to the right lower quadrant 5
• In pregnant patients, pain location may not correlate reliably with appendicitis 5

Small bowel pathology:

• Small bowel obstruction, early inflammatory bowel disease, mesenteric ischemia 5

Vascular causes:

• Abdominal aortic aneurysm, mesenteric ischemia 2

Imaging Algorithm

Standard Adult Patients:

• First-line: CT abdomen and pelvis with IV contrast 1, 2
• If IV contrast contraindicated: Unenhanced CT (similar accuracy in elderly ≥75 years) 1

Special Populations:

Pregnant patients:

• First-line: Ultrasound 1
• If equivocal: Non-contrast MRI 5
• Always obtain pregnancy test in women of reproductive age before imaging 2

Young patients (radiation concern):

• First-line: Ultrasound 1

Premenopausal women with suspected gynecologic pathology:

• First-line: Pelvic/transvaginal ultrasound 6

Essential Laboratory Tests

Order the following first-line tests for all patients:

• Complete blood count 2
• Comprehensive metabolic panel 2
• Pancreatic enzymes (amylase and lipase) 2
• Urinalysis 2
• Pregnancy test (all women of reproductive age) 2

Imaging Modalities to Avoid

Plain radiography:

• Limited utility due to low sensitivity for most causes of LUQ and umbilical pain 1, 2
• May detect pneumoperitoneum or bowel obstruction but should not be relied upon as sole imaging 1

MRI:

• Not recommended for initial evaluation of acute pain due to longer acquisition time, less sensitivity for extraluminal air, motion artifacts, and need for contraindication screening 1
• May be useful as second-line imaging if CT is non-diagnostic and symptoms persist 2

Fluoroscopic contrast enema:

• Not recommended as initial imaging 1

Critical Pitfalls to Avoid

• Do not rely solely on plain radiographs which have poor sensitivity for most causes of LUQ and umbilical pain 1
• Do not fail to use contrast enhancement when evaluating for vascular pathologies or abscesses 1
• Do not delay appropriate imaging in elderly patients who may present with atypical symptoms and normal laboratory values 1
• Do not assume normal laboratory values exclude serious pathology—imaging may still be necessary based on clinical presentation 2
• Do not miss ectopic pregnancy by failing to obtain pregnancy test before imaging in women of reproductive age 2
• Do not overlook atypical presentations such as appendicitis with malrotation presenting as LUQ pain 3

Management of Specific Conditions

If Diverticulitis Identified (typically left lower quadrant but can extend):

Uncomplicated diverticulitis:

• Conservative treatment without antibiotics in immunocompetent patients with CT diagnosis 5
• Antibiotic therapy for ≤7 days in immunocompromised/elderly patients 5

Complicated diverticulitis with abscess:

• Small abscesses: Antibiotic therapy alone for 7 days 5
• Large abscesses: Percutaneous drainage combined with antibiotic therapy for 4 days 5

If Acute Cholecystitis Identified (may refer to LUQ):

Uncomplicated:

• Early laparoscopic/open cholecystectomy within 7-10 days of symptom onset 5
• One-shot prophylaxis if early intervention; no post-operative antibiotics 5

Complicated:

• Laparoscopic cholecystectomy plus antibiotic therapy for 4 days in immunocompetent patients if source control adequate 5
• Up to 7 days in immunocompromised or critically ill patients 5

If Acute Cholangitis Identified:

• Biliary drainage plus antibiotic therapy for 4 days in immunocompetent, non-critically ill patients if source control adequate 5
• Up to 7 days in immunocompromised or critically ill patients 5
• ERCP, PTC, or open surgical drainage based on severity and availability 5