Left Upper Quadrant Pain

The crude differential diagnosis for LUQ pain is vast but after adequate history and examination it should be very much smaller. Common things commonly occur but rarities do happen and atypical presentations may also be misleading. A systematic approach and an open mind are required.

Enquire first about the pain:

• Ask the patient to point to where it is. Does the patient use a single finger or is it more diffuse?
• When did it start?
• Was the onset sudden or gradual?
• Is it continuous or intermittent?
• Ask the patient to describe the nature of the pain. It may be stabbing, burning, gripping etc. Note the body language and use of hands.
• Are there any aggravating or relieving factors?
• Does the pain radiate anywhere?
• The patient may volunteer information such as pyrexia, cough or dysuria or direct enquiry should be made.
• Note past medical or surgical history.

Make a systematic enquiry:

• Appetite
• Weight
• Bowels
• Urine
• Smoking and drinking
• Medication
• When last ate or drank (important if general anaesthesia is considered)
• Family history may be revealing, eg black child with a sickle cell disease in the family.

Abdominal examination is described in rather more detail elsewhere.

• Note the general condition of the patient, eg fairly well, shocked, pyrexial, dyspnoeic.
• Note temperature, pulse rate and quality, BP, respiratory rate.
• With the patient adequately disrobed, get comfortable and conduct a systematic examination of the abdomen.
  • Note distension, scars, colour, bruising, stigmata, visible peristalsis or signs of dehydration.
  • Palpation - soft or rigid, tender, guarding, organomegaly or mass present.
  • Listen to bowel sounds, take a full minute
  • Check hernial orifices
  • Check genitals and if appropriate conduct a PR or PV examination
  • In children try to distract them during examination or ask them to jump or hop a few times to assess the severity of the pain.
• If the diagnosis is still elusive examine the respiratory system.

The following list is not in order of likelihood. Consider the history, including age and sex of the patient. Consider the physical findings. This will enable most of the list to be excluded.

• Lesions of the splenic flexure including carcinoma, diverticulosis, ischaemic colitis, constipation or Crohn's disease. Perforation of the gut.
• Irritable bowel syndrome.
• Splenic infarction or congestion. This usually occurs in a very large spleen as in a reticulo-endothelial malignancy but in sickle cell disease spontaneous infarction in children often leads to auto-splenectomy. The spleen can be damaged by blunt trauma.
• Hepatosplenomegaly can occur with malignancy such as a lymphoma or chronic myeloid leukaemia or with auto-immune disease like primary biliary cirrhosis. It may also occur in portal hypertension or some infections such as glandular fever.
• Pyelonephritis, nephrolithiasis, hydronephrosis, renal carcinoma or other disease of the kidney or ureter, including obstruction of the urinary tract.
• Disease of the upper GI tract including dyspepsia, peptic ulcer, gastric malignancy or gastritis.
• Pain can be referred from the heart in acute myocardial infarction or pericarditis. This is uncommon but must be remembered.
• Disease of the left lower lobe of the lungs. This might be a lobar pneumonia or infarction from pulmonary embolism. If the latter is suspected check for evidence of deep vein thrombosis.
• Mesenteric adenitis occurs in children. There will usually be features of viral infection with mild pyrexia and probably other lymphadenopathy.
• Herpes zoster can present as pain before the typical vesicles appear on the skin. It is the skin that is tender rather than deeper.
• Referred pain from nerves in the spinal column or peripheral nerves that supply the area.
• Subphrenic abscess or even gas after laparotomy or laparoscopy. Pain may also be referred to the shoulder.
• Disease of the adrenals including tuberculosis and metastatic carcinoma.

Other considerations:

• Pain from the pancreas tends to be central and higher in the back, often between the scapulae. Amylase is raised in intestinal obstruction but in acute pancreatitis it is very high.
• Carcinoma of pancreas tends to produce an aching pain between the scapulae, eased on leaning forward. Pain from the pancreas can be atypical and misleading.
• Pain from a dissecting abdominal aortic aneurysm is often lower but may well be in the upper abdomen. Other arteries can have aneurysms and bleed, even the splenic artery.
• Gynaecological pain is not always confined to the pelvis. It can present rather higher in Meigs syndrome, ovarian torsion or carcinoma. In late pregnancy structures are displaced and diagnosis is more difficult.
• Appendicitis usually starts as pain around the umbilicus and moves to the RIF but it can be deceptive.
• Meckel's diverticulum can present in a variety of ways, again in children. The diagnosis is usually made at laparotomy. There is often blood loss per rectum.
• Children are very non-specific about "tummy pain" and almost anything can present as such. Check ears, throat, chest and urine.

This list is by no means exhaustive. There are many other rarer causes of abdominal pain including an Addisonian crisis, Familial Mediterranean Fever, diabetic keto-acidosis, tabes dorsalis and worm infestation. Consider the possibility of Munchausen syndrome.

The choice of investigations will depend upon the findings above.

• FBC, ESR may give an indication of infection or an inflammatory process. Bleeding may cause anaemia. This may indicate malignancy. Abnormalities of splenic function may be apparent on a film. Hypersplenism can cause thrombocytopenia.
• Abnormal LFTs will occur if the liver is involved and in primary biliary cirrhosis there will be positive autoantibodies for mitochondria. It usually presents in a middle-aged woman with jaundice and pruritus.
• Urinalysis may suggest UTI including pyelonephritis or a lesion that causes slight bleeding such as stones or malignancy.
• Chest x-ray with lateral may show a lesion of the left lower lobe. Collapse from infection and infarction look similar. Plain abdominal x-rays, erect and supine, may show abnormal bowel patterns, fluid levels or gas or fluid under the diaphragm. 70% of renal stones are radio-opaque.
• Endoscopy is the investigation of choice for an upper GI lesion.
• Colonoscopy or double contrast barium enema may be required for colonic lesions.
• Ultrasound is useful to investigate the renal tract for stones or dilatation.
• ECG may show abnormalities of myocardial infarction or pericarditis. Cardiac enzymes and troponins may be elevated.
• To investigate the spinal column CT is good at revealing lesions of bone but MRI is better at showing lesions of the nervous system.
• Abdominal CT or MRI may be useful to define a lesion. Radio-isotope imaging can show the liver and spleen.