What is the appropriate evaluation and management for a patient presenting with a cough and left upper quadrant pain?

Evaluation and Management of Cough with Left Upper Quadrant Pain

CT abdomen and pelvis with IV contrast is the preferred initial imaging modality for evaluating left upper quadrant pain in patients presenting with cough, as it provides comprehensive assessment of pulmonary, splenic, pancreatic, gastric, and vascular pathology that may explain both symptoms. 1

Initial Clinical Assessment

The combination of cough and left upper quadrant pain requires evaluation for both pulmonary and intra-abdominal pathology:

Key Clinical Features to Assess

• Fever and leukocytosis indicate inflammatory or infectious processes requiring urgent imaging 1
• Rebound tenderness with abdominal distension occurs in 82.5% of patients with peritonitis and suggests serious intra-abdominal pathology 1
• Tachycardia is the most sensitive early warning sign of surgical complications and should trigger urgent investigation 2
• Pain characteristics: Severe pain out of proportion to examination findings suggests mesenteric ischemia 2

Critical Red Flags Requiring Emergency Evaluation

• Fever with inability to pass gas/stool, severe tenderness with guarding, vomiting, bloody stools, or signs of shock 3
• Hemodynamic instability suggesting bleeding or sepsis 2
• Signs of peritonitis (rigid abdomen, rebound tenderness) 2

Diagnostic Imaging Strategy

Primary Imaging Recommendation

CT abdomen and pelvis with IV contrast (rated 8/9 "usually appropriate" by the American College of Radiology) 1

This modality:

• Detects free intraperitoneal air with 92% positive predictive value for perforation 1
• Alters diagnosis in nearly half of cases with nonlocalized abdominal pain 1
• Identifies alternative diagnoses in 49% of patients 1
• Has 69% sensitivity and 100% specificity for acute abdominal abnormalities in left upper quadrant pain 4

Chest Imaging Considerations

Chest radiography should be obtained initially to evaluate the pulmonary contribution to cough 5

• If chest X-ray is normal or shows insignificant findings, proceed with systematic evaluation for common causes of chronic cough 5
• Chest CT is NOT routinely indicated for chronic cough with normal chest radiograph unless clinical suspicion exists for underlying pulmonary disease 5
• Chest CT should be reserved for patients with abnormal chest radiographs or high clinical suspicion for bronchiectasis, interstitial lung disease, or malignancy 5

Alternative Imaging (Limited Utility)

• Plain radiography: Very limited diagnostic value for left upper quadrant pain 1
• Ultrasound: Limited utility due to overlying bowel gas and rib shadowing, though may identify splenic or renal pathology 1

Differential Diagnosis by System

Pulmonary Causes of Cough

The three most common causes of chronic cough (accounting for 90% of diagnoses) are 5, 6:

1. Upper airway cough syndrome (UACS/postnasal drip) - most common 5
2. Asthma - second most common 5
3. Gastroesophageal reflux disease (GERD) - third most common 5

These three conditions cause chronic cough in 99.4% of nonsmokers not taking ACE inhibitors with normal/stable chest radiographs 6

Abdominal Causes of Left Upper Quadrant Pain

Splenic pathology: Infarction, rupture, abscess, or enlargement 1

Pancreatic disease:

• Pancreatitis confirmed by serum amylase >4× normal or lipase >2× upper limit 1
• Overall mortality <10%, <30% in severe disease 1

Gastric abnormalities: Gastritis, peptic ulcer disease 1

Splenic flexure pathology: Diverticulitis or colitis extending to left upper quadrant 1

Renal pathology: Nephrolithiasis or pyelonephritis 1

Vascular conditions: Mesenteric ischemia (consider if postprandial pain with weight loss and atherosclerotic risk factors) 1

Rare causes: Internal herniation with atypical appendicitis 1, 7

Management Algorithm

Step 1: Immediate Assessment (Emergency Department)

1. Obtain vital signs - assess for fever, tachycardia, hypotension, tachypnea 2
2. Physical examination - evaluate for peritoneal signs, rebound tenderness, abdominal distension 1, 2
3. Laboratory tests:
   • Complete blood count for leukocytosis 2
   • Serum amylase and lipase if pancreatitis suspected 1
   • C-reactive protein (superior sensitivity/specificity compared to WBC for surgical disease) 2
   • Lactate if ischemia or sepsis suspected 2
   • Beta-hCG in women of childbearing age 2

Step 2: Imaging

Order CT abdomen and pelvis with IV contrast 1

• Oral or colonic contrast may be helpful for bowel luminal visualization 5
• Also obtain chest radiograph to evaluate pulmonary contribution 5

Step 3: Management Based on CT Findings

If CT shows acute pathology requiring intervention:

• Free intraperitoneal air → immediate surgical consultation 1
• Abscess → consider percutaneous drainage, broad-spectrum antibiotics 1
• Pancreatitis → supportive care with IV fluids, pain control, antiemetics 1
• Perforation → NPO status, IV fluid resuscitation, nasogastric decompression, surgical consultation 1

If CT is negative for acute abdominal pathology:

Proceed with systematic evaluation for chronic cough 5:

1. Trial of first-generation antihistamine-decongestant for UACS (expect improvement within 1-2 weeks, complete resolution may take months) 5

2. If partial response, add topical nasal steroid or obtain sinus imaging for chronic sinusitis 5

3. If no response to UACS treatment, evaluate for asthma with pulmonary function testing and empiric bronchodilator trial 5

4. If asthma treatment fails, treat empirically for GERD with proton pump inhibitors (response may take weeks to months) 5

5. Consider metoclopramide if GERD treatment inadequate 5

Step 4: Advanced Evaluation if Initial Workup Negative

High-resolution chest CT should be performed if:

• All empiric treatments for UACS, asthma, and GERD have failed 5
• To evaluate for bronchiectasis or occult interstitial disease 5

Bronchoscopy indicated if:

• HRCT shows bronchiectasis or interstitial lung disease 5
• To look for occult airway disease (endobronchial tumor, sarcoidosis, eosinophilic/lymphocytic bronchitis) 5

Common Pitfalls to Avoid

• Do not dismiss left upper quadrant pain as benign without imaging when clinical suspicion exists - CT alters diagnosis in nearly half of cases 1
• Do not routinely order chest CT for chronic cough with normal chest radiograph - low clinical yield unless specific clinical suspicion exists 5
• Do not rely on normal laboratory values early in disease - many tests are nonspecific and may be normal despite serious infection, especially in elderly patients 2
• Recognize that cough is often multifactorial (59% have multiple causes) - sequential and additive therapy may be crucial 5, 6
• Do not expect immediate response to treatment - UACS may take weeks to months to resolve, GERD treatment may require prolonged therapy 5
• Character, timing, and complications of cough are NOT diagnostically useful for determining etiology 6

Special Population Considerations

Elderly patients: May present with atypical symptoms and normal laboratory tests despite serious pathology; have higher likelihood of malignancy, diverticulitis, and vascular causes 2

Post-bariatric surgery patients: Tachycardia is the most critical warning sign; classic peritoneal signs often absent; consider internal herniation even with normal lactate 2