What are the treatment options for left upper abdominal pain?

Left Upper Abdominal Pain: Diagnostic and Treatment Approach

For left upper abdominal pain, immediately obtain CT abdomen/pelvis with IV contrast as the diagnostic test of choice, which has 98% diagnostic accuracy and changes diagnosis in 49% of cases, while simultaneously assessing for life-threatening conditions requiring emergent surgical intervention. 1, 2

Immediate Life-Threatening Assessment

Check vital signs immediately for hypotension, tachycardia, or altered mental status, as these indicate possible intra-abdominal hemorrhage from splenic rupture or other vascular catastrophe requiring emergent surgery. 1

• Assess for referred left shoulder pain (Kehr's sign), which suggests diaphragmatic irritation from blood or fluid in the left upper quadrant, most commonly from splenic pathology. 1
• Examine for peritonitis by checking for diffuse tenderness, guarding, rebound tenderness, or absent bowel sounds, which indicate possible perforation requiring emergent surgery. 1
• Evaluate for pain out of proportion to exam findings, which is the hallmark of mesenteric ischemia carrying 30-90% mortality and requires immediate vascular imaging. 1
• Obtain ECG and troponin to exclude acute coronary syndrome, which can present with epigastric or left upper quadrant pain. 1

Diagnostic Imaging Strategy

CT abdomen/pelvis with IV contrast is the preferred initial imaging study for left upper quadrant pain, providing superior evaluation of splenic, pancreatic, gastric, and vascular pathology compared to other modalities. 1, 2

• CT with IV contrast detects splenic hematoma, laceration, infarction, abscess, pancreatic inflammation, gastric perforation, and alternative diagnoses including renal pathology. 1
• Do not rely on clinical assessment alone, as misdiagnosis rates range from 34-68% without imaging. 1
• In pregnant patients, if ultrasonography is inconclusive, magnetic resonance imaging is preferred over CT when available. 2

Essential Laboratory Investigations

Order immediately: 3

• Complete blood count (leukocytosis >14,000 suggests infection, ischemia, or inflammation)
• Metabolic panel with lactate (elevated lactate and low bicarbonate indicate intestinal ischemia)
• C-reactive protein
• Lipase (for pancreatitis evaluation)
• Hepatobiliary markers
• Urinalysis
• Pregnancy test in reproductive-age patients

Differential Diagnosis by Pathology

Splenic Pathology

• Splenic rupture or subcapsular hematoma presents with left upper quadrant pain, left shoulder pain, and potential hemodynamic instability requiring immediate surgical consultation. 1
• Splenic infarction causes acute left upper quadrant pain and may occur in patients with atrial fibrillation, endocarditis, or hypercoagulable states. 1

Gastric and Pancreatic Pathology

• Gastric perforation presents with sudden severe pain, peritonitis, and free air on CT requiring emergent surgery. 1
• Boerhaave's syndrome (spontaneous esophageal rupture) presents with upper abdominal pain after excessive vomiting and has high mortality if untreated. 4
• Pancreatitis causes epigastric pain radiating to the back with elevated lipase and CT findings of pancreatic inflammation. 1

Renal Pathology

• Left renal colic from urolithiasis causes left upper quadrant pain radiating to the flank and groin, diagnosed by CT showing hydronephrosis or stones. 1
• Pyelonephritis presents with fever, costovertebral angle tenderness, and pyuria. 1

Functional Disorders

• Functional dyspepsia involves upper abdominal or epigastric pain present in fasting conditions and/or precipitated by meal ingestion, unrelated to defecation. 5
• Pain in functional dyspepsia should be bothersome and present for more than 8 weeks to meet Rome IV criteria. 5

Age-Specific Considerations

In patients ≥60 years with abdominal pain, obtain urgent CT imaging to exclude pancreatic cancer and other malignancies, particularly with persistent symptoms. 3

• Consider urgent CT scan for abdominal pain and weight loss if age ≥60 years. 5
• Do not dismiss symptoms as functional dyspepsia without proper investigation in patients ≥60 years with new-onset symptoms, as colorectal cancer causes 60% of large bowel obstructions in this age group. 3

Management Algorithm

Immediate Stabilization

• Activate massive transfusion protocol if splenic rupture with hemorrhagic shock is suspected. 1
• Initiate IV crystalloid resuscitation if the patient is hemodynamically unstable. 3
• Emergency surgical consultation is required for signs of peritonitis, free air on CT, hemodynamic instability, or clinical deterioration despite medical management. 1

Medical Management

• Initiate supportive care with IV fluids, antiemetics, and analgesics (avoid NSAIDs if bleeding suspected). 1
• For pain control, intravenous administration of paracetamol, dipyrone, or piritramide are currently the analgesics of choice in the emergency setting. 6
• Combinations of non-opioids and opioids should be administered in patients with moderate, severe, or extreme pain. 6

Infection Management

If intra-abdominal infection is identified: 1

• For community-acquired infection: Ertapenem 1g q24h or Eravacycline 1mg/kg q12h
• For septic shock: Meropenem 1g q6h by extended infusion, Doripenem 500mg q8h by extended infusion, or Imipenem/cilastatin 500mg q6h by extended infusion
• Duration: 4 days post-source control for uncomplicated infections in immunocompetent patients, extending to 7 days for immunocompromised or critically ill patients

Functional Dyspepsia Management (After Exclusion of Organic Disease)

• Establish effective and empathic doctor-patient relationship and explain the diagnosis in the context of the gut-brain axis. 5
• Baseline investigations include: Full blood count in patients aged ≥25 years, coeliac serology in patients with overlap of IBS-type symptoms, and breath or stool testing for H. pylori. 5
• Consider empirical acid suppression therapy with ranitidine 150 mg twice daily for symptomatic relief, which commonly occurs within 24 hours. 7
• Concomitant antacids should be given as needed for pain relief. 7

Critical Pitfalls to Avoid

• Do not delay imaging in patients with left shoulder pain accompanying left upper quadrant pain, as this combination suggests serious intra-abdominal pathology. 1
• Do not administer NSAIDs until bleeding sources are excluded, as they can worsen hemorrhage. 1
• Do not discharge patients with unexplained left upper quadrant pain and shoulder pain without definitive imaging, as delayed splenic rupture can occur hours to days after initial injury. 1
• Do not overlook malignancy in elderly patients, as CT changes diagnosis in approximately 50% of cases with nonspecific pain. 3
• Recent changes in diet, alcohol excess, or drugs that can alter gut motility (opioids or NSAIDs) should be documented, as NSAIDs are associated with dyspepsia in multiple population-based studies. 5