What are the implications of a bruise over the left upper quadrant (LUQ) of the abdomen?

Bruise Over Left Upper Quadrant: Clinical Implications and Management

A bruise over the left upper quadrant (LUQ) following trauma mandates immediate evaluation for splenic injury, as this physical finding represents a potential marker of significant intra-abdominal pathology that may require urgent intervention.

Initial Assessment and Risk Stratification

The presence of LUQ ecchymosis should trigger a systematic evaluation protocol:

• Hemodynamic status is the primary determinant of management pathway – unstable patients require immediate surgical consultation regardless of imaging findings 1
• LUQ bruising in blunt trauma suggests direct impact and raises suspicion for splenic injury, left renal injury, pancreatic tail injury, or left-sided rib fractures 1, 2
• Associated findings that increase concern include lower left rib fractures, supra-umbilical seat belt signs, or upper lumbar spine fractures 1

Diagnostic Approach Based on Hemodynamic Status

For Hemodynamically Unstable Patients:

• Perform bedside FAST examination immediately to detect free intraperitoneal fluid 3, 4
• FAST should systematically evaluate four LUQ spaces: pleural space, subphrenic space, splenorenal space, and left paracolic gutter 1, 3
• Proceed directly to laparotomy if free fluid is detected, regardless of whether solid organ injury is identified 3

Critical caveat: FAST has only 79% sensitivity with 93% negative predictive value in hypotensive patients – a negative FAST does not exclude injury and should never preclude surgical exploration in unstable patients 3, 4.

For Hemodynamically Stable Patients:

• CT abdomen/pelvis with IV contrast is the definitive diagnostic test, with 97% sensitivity and 95% specificity for injuries requiring intervention 3, 4
• CT is specifically superior for detecting pancreatic injuries, which FAST routinely misses 4
• Portal venous phase imaging is optimal for solid organ injury detection 1

The evidence strongly supports CT over serial FAST examinations in stable patients, as FAST has poor sensitivity (68-91%) for detecting all intra-abdominal injuries and frequently misses bowel and pancreatic injuries 4.

Specific Injury Considerations

Splenic Injury:

• Non-operative management is preferred for grade III splenic injuries without contrast extravasation in hemodynamically stable patients 1
• Previous LUQ surgery does not contraindicate non-operative management (95% expert consensus) 1
• Free fluid in the LUQ occurs in 32% of positive FAST examinations, with 84% of LUQ fluid also visible in the left paracolic gutter 5
• Only 6% of patients have free fluid isolated to the LUQ alone 5

Pancreatic Injury:

• Serum amylase and lipase should be measured, though normal levels within 3-6 hours do not exclude injury 1
• Persistently elevated or rising amylase/lipase measured every 6 hours has prognostic significance 1
• CT with IV contrast may be essential for diagnosing pancreatic injuries, particularly pancreatic duct disruption 1

Renal Injury:

• Isolated renal laceration with perirenal hematoma can present with severe LUQ pain without free intraperitoneal fluid 2
• Serial FAST examinations can safely exclude free fluid and allow confident transport to CT 2

Non-Trauma Differential Considerations

When trauma history is absent or remote:

• Splenic infarction presents with LUQ pain, fever, nausea, and vomiting, appearing as wedge-shaped peripheral low-density areas on CT 6, 7
• Most splenic infarcts are managed conservatively with supportive care 6, 7
• CT abdomen/pelvis with IV contrast has up to 98% accuracy for diagnosing causes of left-sided abdominal pain 3, 8

Management Algorithm Summary

For patients with LUQ bruising:

1. Assess hemodynamic stability immediately
2. If unstable: Bedside FAST → Laparotomy if positive (or if high clinical suspicion despite negative FAST)
3. If stable: CT abdomen/pelvis with IV contrast
4. Monitor serial amylase/lipase every 6 hours if pancreatic injury suspected 1
5. Consider non-operative management for isolated splenic injuries in stable patients 1

Common pitfall: Relying on a negative FAST examination to exclude significant injury in patients with concerning mechanism or physical findings. The American College of Emergency Physicians emphasizes that negative or inconclusive FAST should never be the sole diagnostic test 4.