What is the management approach for differential left lateral rib pain?

Management of Left Lateral Rib Pain

For left lateral rib pain, immediately obtain CT abdomen and pelvis with IV contrast to exclude life-threatening intra-abdominal pathology, then systematically palpate the costal margin to diagnose painful rib syndrome if imaging is negative. 1

Initial Diagnostic Approach

Immediate Red Flag Assessment

• Obtain CT abdomen and pelvis with IV contrast emergently if the patient presents with fever, inability to pass gas or stool, severe abdominal tenderness with guarding, vomiting, bloody stools, signs of shock, or progressively worsening pain—these indicate potential diaphragmatic hernia, splenic pathology, or perforated viscus requiring urgent intervention. 2, 1, 3

• Rebound tenderness with abdominal distension occurs in 82.5% of patients with peritonitis and mandates immediate emergency surgical evaluation for possible perforation or abscess. 1

• Free intraperitoneal air on CT indicates perforation requiring surgical consultation, while free intraperitoneal fluid with peritoneal enhancement suggests peritonitis. 1

Imaging Strategy for Serious Pathology

• CT abdomen and pelvis with IV contrast is rated 8/9 (usually appropriate) by the American College of Radiology and provides comprehensive assessment of splenic pathology, pancreatic disease, gastric abnormalities, diaphragmatic hernias, and vascular conditions. 1

• CT alters diagnosis in nearly half of cases and should not be dismissed without imaging when clinical suspicion exists for intra-abdominal pathology. 1

• Plain radiography has very limited diagnostic value for left lateral rib pain, though chest X-ray is recommended as first-line for suspected diaphragmatic hernia in patients without trauma history. 2, 1

• Ultrasound has limited utility in this location due to overlying bowel gas and rib shadowing, though it may identify splenic or renal pathology. 1

Differential Diagnosis by Clinical Presentation

If Pain Associated with Trauma or Recent Injury

• Rib fractures are present in 15% of all traumas and 60% of patients with chest traumas, causing significant pain that leads to splinting and respiratory compromise. 4

• Surgical stabilization of rib fractures (SSRF) should be considered for patients with ≥3 displaced rib fractures (displacement ≥50% of rib width on CT) who have persistent pain despite medical treatment and respiratory impairment, including respiratory rate >20 breaths/minute, incentive spirometry <50% predicted, or numeric pain score >5/10. 2

• Traumatic diaphragmatic hernia presents with dyspnea (86%) and abdominal pain (17%), with 33-66% missed in the acute phase due to associated injuries. 2

• CT scan with contrast enhancement of chest and abdomen is recommended for stable trauma patients with suspected diaphragmatic hernia. 2

If Pain Reproduced by Palpation of Costal Margin

• Painful rib syndrome is the diagnosis when three features are present: pain in the lower chest or upper abdomen, a tender spot on the costal margin, and reproduction of pain on pressing the tender spot. 5

• This accounts for 3% of new referrals to gastroenterology clinics and is common but underdiagnosed, requiring no investigation once serious pathology is excluded. 5

• Painful rib syndrome is a variant of myofascial pain syndrome and responds well to noninvasive supportive interventions. 6

• The most critical intervention is explaining the benign nature of the condition and providing support that the pain is real and can be managed. 6

If Pain Associated with Eating

• Consider chronic mesenteric ischemia if the patient has postprandial pain with weight loss and atherosclerotic risk factors, and obtain CT angiography to evaluate for mesenteric ischemia. 1

• Functional dyspepsia should be considered when testing reveals no structural abnormality, characterized by pain or burning in the upper abdomen, early satiety, or postprandial heaviness. 1

If Pain Associated with Left Lower Quadrant Symptoms

• Acute diverticulitis is the most common cause of left lower quadrant pain in adults, affecting 5-25% of patients with diverticulosis. 7

• CT abdomen and pelvis with IV contrast has 98% diagnostic accuracy for diverticulitis and is rated 8/9 (usually appropriate) by the American College of Radiology. 3, 7

Treatment Algorithm Based on Findings

For Confirmed Rib Fractures Without Complications

• Multimodal pain management is essential to prevent splinting, atelectasis, and pneumonia—each rib fracture increases pneumonia risk by 27% and mortality by 19% in elderly patients. 4

• SSRF reduces pneumonia rates, ICU length of stay, duration of mechanical ventilation, hospital days, mortality, tracheostomy rate, chest wall deformity, and dyspnea compared to nonoperative management. 2

• Patients with ≥3 painful or displaced rib fractures who undergo SSRF have improved return-to-work rates between 3 and 6 months compared to nonoperative management. 2

For Painful Rib Syndrome (Musculoskeletal)

• Systematic firm palpation of the costal margin is recommended in all patients presenting with pain in the lower chest or upper abdomen to identify the tender spot. 5

• Osteopathic manipulation techniques and instrument-assisted soft tissue mobilization can provide complete resolution of symptoms in atypical costochondritis that does not self-resolve. 8

• Ultrasound-guided intercostal nerve blocks with local anesthetics and triamcinolone can be performed at the point of greatest tenderness for refractory cases. 9

For Diaphragmatic Hernia

• Surgical repair is recommended for symptomatic diaphragmatic hernias, as delayed presentation can lead to visceral obstruction progressing to ischemia of herniated organs. 2

• Diagnostic laparoscopy is recommended for stable trauma patients with lower chest penetrating wounds and suspected diaphragmatic hernia. 2

Common Pitfalls to Avoid

• Do not assume benign musculoskeletal pain without imaging when red flag symptoms are present—clinical examination alone has poor diagnostic accuracy for distinguishing between benign and serious pathology. 1, 3

• Do not miss diaphragmatic hernia in trauma patients, as 33-66% are missed in the acute phase and can present with nonspecific gastrointestinal and respiratory symptoms. 2

• Do not perform extensive investigations for painful rib syndrome once serious pathology is excluded—43% of patients in one series had been investigated extensively before diagnosis, and eight had undergone non-curative cholecystectomy. 5

• Do not rely on chest X-ray alone for diaphragmatic hernia, as it has sensitivity of only 2-60% for left-sided hernias and normal radiographs occur in 11-62% of cases. 2

• Pain that varies with respiration, body position, or food intake, is well-localized on the chest wall, or is accompanied by local tenderness indicates a less severe condition. 2