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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
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: Right Upper Quadrant Pain, Abdominal Pain, Abdominal Pain in Pregnancy, and Acute Abdominal Pain in Children.
- Pain: onset, nature, time course, radiation, exacerbating or relieving factors.
These points can be remembered with the mnemonic 'SOCRATES': [Site] [Onset] [Character] [Radiation] [Associated symptoms][Time] [Exacerbating/relieving] [Severity].
- Women: establish whether pregnancy is possible. Last menstrual period date - ask whether this period was normal.
- 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.
- 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.
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.
The crude differential diagnosis is vast but after adequate history and examination it should be very much smaller. The following order is not intended to indicate likelihood:
Possible causes of LUQ pain include
- Cardiac pain - angina or myocardial infarction (may have central chest pain).
- Subacute bacterial endocarditis.
- Lung - left lower lobe pneumonia or pleurisy.
- 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 - eg, with sickle cell crisis.
- Acute splenic sequestration - eg, a child with sickle cell disease and acute anaemia.
- Splenic infiltration - eg, leukaemia or other malignancy.
- Ruptured spleen - due to chest/abdominal trauma:
- Stomach (may have epigastric pain, LUQ pain or back pain):
- Kidney (may have loin pain):
- Colon - left colon and splenic flexure (may have low abdominal pain or left flank pain):
- Pancreas (may have epigastric or back pain):
- Diaphragm and peritoneum (location of pain depends on which area of peritoneum is involved; may have shoulder-tip pain if the diaphragm is irritated):
- Chest and abdominal wall:
- Remember 'medical' causes of abdominal pain (not necessarily LUQ pain):
- Blood tests - cross-match if bleeding; FBC, renal and liver function, glucose; consider serum beta-hCG, sickle test, amylase, calcium, hepatitis serology, ESR/CRP.
- ECG - for cardiac ischaemia or pre-operatively.
- Urine microscopy and culture; pregnancy test if appropriate.
- 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 (although CT KUB may be preferred).
- 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 scanning: CT of the abdomen with or without contrast is often employed. MRI is the preferred option in pregnancy, although CT scanning is increasingly being used in pregnancy in specific cases - eg, it is the most reliable method of diagnosing patients with suspected obstruction of the urinary tract due to calculus. Studies suggest that the risk to the fetus from the ionising radiation involved in CT scanning is minimal. If a risk-benefit analysis confirms that CT would be in the patient's best interests, it should not be withheld.
- Diagnostic laparoscopy (followed by laparoscopic surgery, if appropriate).
Approach to diagnosis and management
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 - eg:
- The elderly.
- Those with learning difficulties.
- Those with 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.
- 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.
Further reading and references
Kao YT, Shih CM, Tsao NW, et al; Subacute bacterial endocarditis presenting as left upper quadrant abdominal pain. J Chin Med Assoc. 2013 Sep76(9):521-3. doi: 10.1016/j.jcma.2013.05.010. Epub 2013 Jun 25.
Wong JW, Chin JM, Schlueter RJ; Shingles in Pregnancy: An Elusive Case of Left Upper Quadrant Abdominal Pain. Hawaii J Med Public Health. 2018 Aug77(8):179-182.
Cartwright SL, Knudson MP; Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician. 2015 Apr 191(7):452-9.
Tirkes T, Ballenger Z, Steenburg SD, et al; Computerized tomography of the acute left upper quadrant pain. Emerg Radiol. 2016 Aug23(4):353-6. doi: 10.1007/s10140-016-1410-5. Epub 2016 May 26.