What are possible medical causes of a dull left‑sided ache in a 54‑year‑old woman?

Differential Diagnosis of Dull Left-Sided Ache in a 54-Year-Old Woman

A 54-year-old woman with dull left-sided ache requires immediate consideration of cardiac causes—particularly acute coronary syndrome—because women in this age group are at significant risk for underdiagnosis of cardiac disease and commonly present with atypical symptoms including left-sided chest discomfort. 1

Life-Threatening Cardiac Causes (Must Rule Out First)

Acute coronary syndrome (ACS) is the most critical diagnosis to exclude, as women aged 54 are at peak risk and frequently present with atypical symptoms:

• Women commonly present with accompanying symptoms beyond typical chest pain, including jaw/neck pain, back pain, epigastric discomfort, shortness of breath, nausea, diaphoresis, and palpitations 1
• Traditional risk assessment tools systematically underestimate cardiac risk in women and frequently misclassify their chest pain as nonanginal 1
• Dull ache on the left side can represent anginal equivalent symptoms, particularly in women, diabetics, and middle-aged patients 1
• Women with cardiovascular risk factors (hypertension, hyperlipidemia, family history, sedentary lifestyle) have higher prevalence of coronary disease than clinical assessment suggests 1

Immediate action required: Obtain 12-lead ECG within 10 minutes and measure cardiac troponin immediately if any cardiac risk factors are present 2

Gastrointestinal Causes (If Cardiac Workup Negative)

Acute Diverticulitis

If the pain localizes to the left lower quadrant, acute sigmoid diverticulitis becomes the most common cause in this age group:

• Diverticulitis is the most frequent cause of left lower quadrant pain in adults, with prevalence increasing significantly after age 50 1, 3, 4
• Classic triad includes left lower quadrant pain, fever, and leukocytosis, though this occurs in only 25% of cases 3
• CT abdomen and pelvis with IV contrast is the definitive diagnostic test with 98% accuracy (rated 8/9 by the American College of Radiology) 1, 3, 4
• Clinical examination alone has misdiagnosis rates of 34-68% 3

Other Gastrointestinal Pathology

Additional causes depend on precise pain location:

• Colitis, inflammatory bowel disease, epiploic appendagitis, bowel obstruction, or fecal impaction if pain is in left mid-to-lower abdomen 1, 4, 5
• Splenic pathology (infarction, rupture, or enlargement) if pain is in left upper quadrant 6
• Gastroesophageal reflux disease (GERD) or peptic ulcer disease if pain is epigastric with left-sided radiation 2

Musculoskeletal Causes (Diagnosis of Exclusion)

Only after excluding cardiac and serious abdominal pathology:

• Myofascial pain syndrome affecting left chest wall or flank musculature presents as dull, constant ache with restricted range of motion 7
• Costochondritis causes localized tenderness at costochondral junctions, reproducible with palpation 2
• Critical pitfall: Positional or reproducible chest wall pain does not exclude cardiac ischemia in women, who may have both musculoskeletal and cardiac components 1

Renal/Urologic Causes

• Left-sided urolithiasis or pyelonephritis should be considered, particularly if pain radiates to flank or back 1, 5
• Unenhanced CT has near 100% sensitivity and specificity for urinary tract calculi 1

Gynecologic Causes (In Premenopausal Women)

• Ovarian or fallopian tube pathology can present as left lower quadrant pain 1, 5
• Pelvic/transvaginal ultrasound is the preferred initial imaging if gynecologic pathology is suspected 3, 4

Algorithmic Diagnostic Approach

Step 1: Immediate Cardiac Assessment

• Obtain focused history emphasizing: radiation to jaw/neck/back, associated dyspnea, diaphoresis, nausea, palpitations 1
• Assess cardiovascular risk factors: hypertension, hyperlipidemia, diabetes, family history, smoking 1
• Order 12-lead ECG and cardiac troponin immediately 2

Step 2: If Cardiac Workup Negative, Localize Pain Precisely

• Left upper quadrant: Consider splenic or gastric pathology; order CT abdomen with IV contrast 6
• Left lower quadrant: Diverticulitis most likely; order CT abdomen/pelvis with IV contrast 1, 3, 4
• Left flank: Consider urolithiasis; order unenhanced CT 1
• Left chest wall: Consider musculoskeletal causes only after cardiac exclusion 2, 7

Step 3: Red Flags Requiring Emergency Evaluation

Activate 9-1-1 or send to ED immediately if any of the following are present:

• Fever, inability to pass gas/stool, severe tenderness with guarding, vomiting, bloody stools, signs of shock 3
• Sudden-onset ripping pain radiating to back (aortic dissection) 1, 2
• Acute dyspnea with chest pain (pulmonary embolism) 2
• Syncope, acute confusion, or unexplained fall in elderly patient 1, 2

Critical Pitfalls to Avoid

• Never assume dull left-sided ache is noncardiac in a 54-year-old woman without comprehensive cardiac workup 1
• Do not use nitroglycerin response as diagnostic criterion—esophageal spasm and GERD also respond to nitroglycerin 1, 2
• Do not rely on clinical examination alone for abdominal causes—imaging is essential for accurate diagnosis 1, 3
• Do not attribute symptoms to anxiety or musculoskeletal causes until life-threatening conditions are excluded 1, 2