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