Synonyms: left subcostal pain, left hypochondrial pain

Left upper quadrant (LUQ) pain means pain in the left upper abdominal region. There are related separate articles on Abdominal Pain, Abdominal Pain in Pregnancy, Abdominal Pain in Childhood.

Aetiology¹

Left upper quadrant (LUQ) pain can originate from the chest, abdomen, diaphragm/peritoneum or from general 'medical' causes. Note that intra-abdominal organs may not localise pain accurately and diaphragmatic pain can be referred to the shoulder tip. Possible causes of LUQ pain include:

• Thoracic causes:
  • Cardiac pain - angina or myocardial infarction (may have central chest pain).
  • Lung - left lower lobe pneumonia or pleurisy.
• Abdominal causes:
  • Aortic aneurysm - rupture or dissection (may have pain in the chest, back, loin or abdomen).
  • Splenic pathology:
    • Ruptured spleen - due to chest/abdominal trauma.
      • Note that this can occur with minimal trauma in patients with glandular fever or haematological disorders.
    • Splenic infarction - e.g. with sickle cell crisis.
    • Acute splenic sequestration - e.g. a child with sickle cell disease and acute anaemia.
    • Splenic infiltration - e.g. leukaemia or other malignancy.
  • Stomach (may have epigastric pain, LUQ pain or back pain).
    • Gastric ulcer, gastritis.
    • Gastric carcinoma.
  • Kidney (may have loin pain):
    • Renal colic or renal stones.
    • Pyelonephritis.
    • Kidney tumours.
  • Colon - left colon and splenic flexure (may have low abdominal pain or left flank pain):
    • Diverticulitis.
    • Inflammatory bowel disease.
    • Ischaemic colitis.
    • Tumours in left colon or splenic flexure.
    • Irritable bowel syndrome.
    • Severe constipation.
  • Pancreas (may have epigastric or back pain):
    • Pancreatitis.
    • Pancreatic tumours.
  • Diaphragm and peritoneum (location of pain depends on which area of peritoneum is involved; may have shoulder-tip pain if the diaphragm is irritated):
    • Peritonitis or intra-abdominal bleeding from any cause.
      • Example - ectopic pregnancy may rarely present with abdominal pain referred to the shoulder tip, due to intra-abdominal bleeding irritating the diaphragm).
    • Subphrenic or pericolic abscess.
    • Perforated peptic ulcer.
    • Gas following laparoscopy.
• Chest and abdominal wall:
  • Localised musculoskeletal pain, e.g. Tietze's syndrome.
  • Referred pain from spine and spinal nerves, e.g. shingles, spinal pathology.
• Remember 'medical' causes of abdominal pain (not necessarily LUQ pain):
  • Diabetic ketoacidosis.
  • Septicaemia.
  • Hypercalcaemia.
  • Henoch-Schönlein purpura.
  • Hereditary angio-oedema.
  • Porphyria.
  • Young children may describe almost any pain as 'tummy pain', so look for causes other than LUQ, e.g. ears.

Assessment¹

History

• Pain: onset, nature, time course, radiation, exacerbating or relieving factors.
• Women: is pregnancy possible? Last menstrual period date - was this a normal period?
• Related symptoms: dysphagia, vomiting, anorexia, micturition and bowels, bleeding, systemic symptoms, chest symptoms, weight loss.
• Past medical history, recent injury or surgery, medication (steroids may mask abdominal signs), allergies, last meal.

Examination¹

• Note if well or ill, vital signs; chest examination if appropriate.
• Abdominal examination including spleen size.
• If aortic aneurysm is suspected, check pulses and blood pressure in both arms.
• Rectal or pelvic examination: not usually required for initial assessment of LUQ pain; consider if it will aid diagnosis or management.
• Young children: examine ears, throat and chest also.
• Bedside tests: urine pregnancy test (consider pregnancy in any woman of childbearing age), urine dipstick, bedside glucose test.

Initial investigations to consider¹

• ECG - for cardiac ischaemia or preoperatively.
• Blood tests - cross-match if bleeding; FBC, renal and liver function, glucose; consider serum beta-hCG, sickle test, amylase, calcium, hepatitis serology, ESR/CRP.
• Urine microscopy and culture; pregnancy test if appropriate.
• X-rays:
  • CXR (erect chest if there is suspected perforation - look for air under the diaphragm).
  • Plain abdominal X-ray.
  • Erect and supine films for obstruction (may show air-fluid levels).
  • Kidney-ureter-bladder (KUB) film for renal colic.

Further investigations¹

• Abdominal and pelvic ultrasound are useful for renal, gynaecological or obstetric pathology, masses, organomegaly, ascites, or abscess. Ultrasound may show acute appendicitis.
• CT or MR scanning: CT is increasingly used in diagnosis of acute abdominal pain, particularly in pregnancy.²
• Endoscopy.
• Diagnostic laparoscopy (followed by laparoscopic surgery, if appropriate).

Approach to diagnosis and management³

In the primary care or A&E setting, the diagnosis may not be clear, so use "management of uncertainty" principles. Aim to decide whether the patient needs admission, surgery or further investigation - and how urgently. General principles are:

• For serious emergencies, start resuscitation if needed, refer and transfer promptly.
• Have a low threshold for referring/admitting those where diagnosis may be difficult, e.g. children, the elderly,⁴ those with learning difficulties or relevant pre-existing illness.
• Pain relief may be needed:
  • Diclofenac (intramuscular or suppositories) is useful for renal colic.
  • For severe pain, intravenous opiate analgesia can be given but titrate small doses and monitor vital signs.
    [*Studies in children and adults have demonstrated that administering intravenous opioids to patients with acute abdominal pain induces analgesia but does not delay diagnosis or adversely affect diagnostic accuracy.⁵
• The clinical picture can change over time: reassess if symptoms persist.
• Consider referral/admission if a patient re-consults with undiagnosed pain.
• If discharging the patient, ensure they understand when to seek help.

Document references

1. Collins D; Differential Diagnosis in Primary Care, Lippincott Williams & Wilkins, ISBN: 9780781768122, 2007
2. Woodfield CA, Lazarus E, Chen KC, et al; Abdominal pain in pregnancy: diagnoses and imaging unique to pregnancy--review. AJR Am J Roentgenol. 2010 Jun;194(6 Suppl):WS14-30.
3. Gray J, Wardrope J, Fothergill DJ; Abdominal pain, abdominal pain in women, complications of pregnancy and labour. Emerg Med J. 2004 Sep;21(5):606-13.
4. Laurell H, Hansson LE, Gunnarsson U; Acute abdominal pain among elderly patients. Gerontology. 2006;52(6):339-44. Epub 2006 Aug 11. [abstract]
5. Klein-Kremer A, Goldman RD; Opioid administration for acute abdominal pain in the pediatric emergency J Opioid Manag. 2007 Jan-Feb;3(1):11-4. [abstract]

Internet and further reading

• Mark T Kinirons and Harold Ellis. French's Index of Differential Diagnosis 14Ed. Hodder Education. November 2005
• Acute abdomen; Paediatric Oncall Child Health Care
• Pain Health Information; Abdominal Pain
• Cartwright SL, Knudson MP; Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008 Apr 1;77(7):971-8. [abstract]