What is the next appropriate step in management for a 48‑year‑old woman with a one‑month history of left upper quadrant pain, normal colonoscopy, normal abdominal and pelvic computed tomography, and unremarkable laboratory studies?

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Upper Endoscopy (EGD) with Possible Endoscopic Ultrasound

For a 48-year-old woman with one month of left upper quadrant pain and negative CT/colonoscopy, the next step is upper endoscopy (esophagogastroduodenoscopy) to evaluate gastric and duodenal pathology that may not be visible on CT imaging. 1

Primary Diagnostic Approach

Why Upper Endoscopy is Indicated

  • Left upper quadrant pain localizes to the stomach, spleen, pancreatic tail, and splenic flexure of the colon — the colonoscopy has already evaluated the colon, and CT has limited sensitivity for mucosal gastric pathology 2, 3

  • Endoscopy can identify gastritis, peptic ulcer disease, gastric erosions, and early mucosal lesions that are frequently missed on cross-sectional imaging, even with IV contrast 2, 4

  • Biopsy capability during endoscopy allows for histologic diagnosis of Helicobacter pylori gastritis, eosinophilic gastritis, intestinal metaplasia, and other inflammatory conditions that present with chronic abdominal pain 5

Additional Endoscopic Techniques

  • If upper endoscopy reveals a submucosal lesion or mass, endoscopic ultrasound (EUS) should be performed to characterize the layer of origin, echogenicity, and vascularity, with 80% diagnostic accuracy for benign lesions 3, 6

  • EUS-guided fine needle aspiration can be performed if a suspicious lesion is identified that requires tissue diagnosis beyond standard mucosal biopsy 3

Gynecologic Evaluation in Premenopausal Women

When to Consider Pelvic Pathology

  • Pelvic/transvaginal ultrasound should be obtained if not already performed, as gynecologic causes are common in premenopausal women with left-sided abdominal pain 1

  • Cyclical pain pattern suggests ovarian or uterine etiology requiring gynecology referral if ultrasound reveals pathology 1

Red Flags Requiring Urgent Re-evaluation

Symptoms Mandating Immediate Action

  • Fever, inability to pass gas/stool, severe tenderness with guarding, vomiting, bloody stools, or hemodynamic instability require emergency department evaluation and repeat CT imaging 1, 7

  • Weight loss, anemia, or change in bowel habits warrant repeat colonoscopy despite the recent normal study, as these suggest occult malignancy 1

If Endoscopy is Negative

Functional Disorder Consideration

  • Functional bowel disorder becomes the most likely diagnosis only after structural pathology has been excluded by both CT and endoscopy 1

  • Initiate a trial of dietary modification and antispasmodic medication for pain-predominant symptoms if all imaging and endoscopy are unrevealing 1, 7

  • Gastroenterology referral is appropriate for persistent symptoms despite conservative measures or if functional disorder management requires specialized care 1

Imaging Alternatives

When MRI May Be Useful

  • MRI abdomen and pelvis can be considered if there is concern for pancreatic pathology (pancreatic tail lesions, chronic pancreatitis) or splenic pathology better visualized on MRI, with sensitivity of 86-94% for inflammatory conditions 1

  • Repeat CT is generally not indicated unless new symptoms develop or significant time has passed since the initial study 1

Common Pitfalls to Avoid

  • Do not attribute chronic LUQ pain to functional disorder without upper endoscopy, as gastric mucosal disease is frequently CT-occult 2, 5

  • Do not overlook gynecologic causes in women of reproductive age — always obtain pelvic ultrasound if not already performed 1

  • Do not delay endoscopy for empiric proton pump inhibitor trial in a patient with one month of persistent pain, as this delays definitive diagnosis 2

References

Guideline

Recurrent Left Lower Quadrant Pain Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Research

Imaging of the upper gastrointestinal tract: endoscopy or radiology?

British journal of hospital medicine (London, England : 2005), 2011

Research

[Evaluation of upper gastrointestinal submucosal lesions by endoscopic ultrasonography].

Acta medica Croatica : casopis Hravatske akademije medicinskih znanosti, 2009

Research

Endoscopic sonography of the upper gastrointestinal tract.

AJR. American journal of roentgenology, 1991

Guideline

Diagnostic Approach and Management for Diarrhea-Predominant Irritable Bowel Syndrome

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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