What is the best approach to diagnose and treat a female patient experiencing left upper quadrant (LUQ) abdominal pain that may be related to hormonal fluctuations?

Left Upper Quadrant Abdominal Pain in Female Patients on Hormonal Therapy

For a female patient experiencing left upper quadrant (LUQ) abdominal pain potentially related to hormonal fluctuations, obtain a pregnancy test immediately, then proceed with CT abdomen/pelvis with IV contrast as the initial imaging study if the diagnosis remains unclear after basic laboratory evaluation. 1

Immediate Critical Actions

Always obtain beta-hCG testing before any imaging in all women of reproductive age presenting with acute abdominal pain, as this is a consensus recommendation that prevents unnecessary radiation exposure and avoids missing ectopic pregnancy. 1, 2

Initial Diagnostic Workup

Laboratory Testing

• Complete blood count, comprehensive metabolic panel, pancreatic enzymes (amylase and lipase), and urinalysis should be ordered as first-line tests for all patients with LUQ pain. 2
• Pregnancy testing is mandatory before proceeding with imaging in reproductive-age women. 1

Imaging Strategy

CT abdomen and pelvis with IV contrast is the imaging modality of choice for LUQ pain when the diagnosis is unclear, with the ability to detect a wide range of pathologies and change management decisions in up to 25% of cases. 2 This recommendation comes from the American College of Radiology Appropriateness Criteria, which provides the highest-level guidance for imaging selection. 1

• Ultrasonography can be considered as an initial alternative, particularly for evaluating splenic pathology, pancreatic conditions, and left kidney abnormalities, with the advantage of no radiation exposure. 2
• Plain radiography has extremely limited diagnostic value for LUQ pain, though it may detect pneumoperitoneum or bowel obstruction in select cases. 2
• MRI may serve as a second-line imaging study if CT is non-diagnostic and symptoms persist, with sensitivity of 86-94% for certain conditions. 2

Differential Diagnosis Specific to LUQ Pain

The differential for chronic LUQ pain includes:

• Splenic pathology (infarction, abscess, hematoma, rupture—particularly relevant in trauma or coagulopathy). 2
• Pancreatic disorders (chronic pancreatitis is the most common pancreatic cause). 2
• Gastric conditions. 2
• Renal pathology (nephrolithiasis can present with LUQ pain). 2
• Colonic disorders (diverticulitis, though more common in left lower quadrant, can cause LUQ pain). 2
• Functional disorders (should only be considered after organic pathology is confidently excluded). 2, 3

Hormonal Considerations

While the provided guidelines do not specifically address hormonal influences on LUQ pain, the mandatory pregnancy testing reflects the importance of considering gynecologic and hormonal factors in reproductive-age women. 1 If gynecologic conditions are primarily suspected, refer to specialized guidelines for acute pelvic pain in the reproductive age group. 1

Management Algorithm

1. Obtain detailed history focusing on: pain characteristics, timing relative to menstrual cycle, associated symptoms, and alarm features (fever, weight loss, persistent vomiting). 2
2. Perform targeted physical examination with attention to LUQ tenderness, peritoneal signs, and masses. 2
3. Order first-line laboratory tests as outlined above, including mandatory pregnancy test. 2
4. Obtain CT abdomen with contrast if diagnosis remains unclear or alarm features are present. 2
5. Treat identified organic pathology according to specific diagnosis. 2
6. Consider functional disorder diagnosis only after organic pathology is confidently excluded; avoid repetitive testing once functional pain diagnosis is established. 2, 3

Critical Pitfalls to Avoid

• Never proceed with imaging without pregnancy testing in women of reproductive age, as this can lead to unnecessary radiation exposure and missed ectopic pregnancy. 2
• Do not rely solely on laboratory tests without appropriate imaging when clinical suspicion warrants further investigation—normal laboratory values do not exclude serious pathology. 2
• Avoid repetitive CT scans once a functional pain diagnosis is established, as the diagnostic yield decreases significantly after the initial scan. 2
• Do not diagnose functional disorders prematurely; organic pathology must be confidently excluded first. 3