Left Upper Quadrant Pain

Synonyms: left subcostal pain, left hypochondrial pain.

Left upper quadrant (LUQ) pain means pain in the left upper abdominal region. Note: there are related articles on Abdominal Pain, Abdominal Pain in Pregnancy, Abdominal Pain in Children.

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 chest, back, loin or abdomen)
  • Splenic pathology:
    • Ruptured spleen - due to chest/abdominal trauma
      • Note: 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. 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 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-Schonlein purpura
  • Hereditary angioedema
  • Porphyria
  • Young children may describe almost any pain as 'tummy pain', so look for causes other than LUQ, e.g. ears.

Assessment

History

• Pain: onset, nature, time course, radiation, exacerbating or relieving factors.
• Women: is pregnancy possible? LMP 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.

Examination

• Note if well or ill, vital signs; chest exam if appropriate.
• Abdominal examination including spleen size.
• If aortic aneurysm 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 consider

• ECG - for cardiac ischaemia or preoperative.
• Blood tests - cross-match if bleeding; full blood count, renal and liver function, glucose; consider serum β-HCG, sickle test, amylase, calcium, hepatitis serology, ESR/CRP.
• Urine microscopy and culture; pregnancy test if appropriate.
• X-rays:
  • Chest x-ray (erect chest if suspected perforation - look for air under diaphragm)
  • Plain abdominal x-ray
  • Erect and supine films for obstruction (may show air-fluid levels)
  • KUB film for renal colic

Further investigations

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

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,² 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.
  • Evidence suggests that pain relief does not adversely affect clinical assessment; it can remove harmful physiological stresses and can improve accuracy of examination.³
• The clinical picture can change over time: re-assess 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.