Left Upper Quadrant Pain

Anatomy is the key to recalling the many causes of abdominal pain in the LUQ by visualizing the structures layer by layer. In the first layer are the skin, abdominal wall, and ribs; in the second layer, the spleen, colon, and stomach; and in the third layer, the pancreas, adrenal gland, kidney, aorta, and spine. Now it is possible to cross-index the organs with the various etiologies contained in the mnemonic VINDICATE (Table 8). The following discussion emphasizes the most important of these.

1. Abdominal wall and ribs. Pain will occur most commonly from herpes zoster, contusion, hernia, rib fracture, or metastatic tumor.
2. Spleen. Painful splenic infarcts are not unusual in subacute bacterial endocarditis (SBE), polycythemia, sickle cell anemia, leukemia, periarteritis nodosa, and other autoimmune disorders. A ruptured spleen is an important consideration in abdominal injuries, particularly those in children and in patients with infectious mononucleosis.
3. Stomach. Acute gaseous distention of the stomach in gastritis, pneumonia, and pyloric obstruction is a common cause of LUQ pain. Gastric carcinoma that extends beyond the wall of the stomach may cause pain. Episodic obstruction of the stomach in the “cascade stomach” should be considered in the differential diagnosis. Herniation of the stomach through the diaphragm occasionally causes LUQ pain.
4. Colon. An inflamed diverticulum or an inflamed splenic flexure from granulomatous colitis may cause pain in the LUQ. Less commonly, the colon develops a perforating or constricting carcinoma in this area, which obstructs the bowel. A mesenteric infarct of the colon, as well as gas or impacted feces in the splenic flexure, may also cause LUQ pain.
5. Pancreas. Acute pancreatitis, pancreatic pseudocyst, and carcinoma of the pancreas may cause LUQ pain.
6. Adrenal gland. Adrenal infarction from emboli or Waterhouse–Friderichsen syndrome may cause pain, but neoplasms rarely do until they have become massive.
7. Kidney. Renal infarct, renal calculus, acute pyelonephritis, and nephroptosis with a Dietl crisis may cause LUQ pain. Perinephric abscess must also be considered.
8. Aorta. Dissecting or atherosclerotic aneurysms of the aorta may cause LUQ pain, especially when they occlude a feeding artery to one of the structures there.
9. Spine. Herniated disc, tuberculosis, multiple myeloma, osteoarthritis, tabes dorsalis, spinal cord tumor, and anything else that may compress or irritate the intercostal nerve roots can cause LUQ pain.

Approach to the Diagnosis

The presence or absence of other symptoms and signs will be most helpful in the diagnosis. In acute cases, a surgeon is consulted and a flat plate of the abdomen, CBC, urinalysis, and perhaps a serum amylase level should be done. If necessary, a CT scan of the abdomen is also done. Gastroscopy and colonoscopy may be desirable before other x-rays are done. In chronic cases, however, an upper GI series, barium enema, and stool examination for blood, ova, and parasites are indicated.

Other Useful Tests

1. Four-quadrant peritoneal tap (ruptured spleen)
2. Quantitative urine amylase
3. IVP (renal calculus)
4. Stool for occult blood (carcinoma, diverticulitis)
5. Gallium scan (diverticulitis, etc.)
6. X-ray of thoracolumbar spine (radiculopathy)
7. Small-bowel series (Meckel diverticulum)
8. Laparoscopy (ruptured viscus or peritonitis)
9. Aortogram (dissecting aneurysm)
10. Lymphangiogram (retroperitoneal sarcoma)
11. Exploratory laparotomy

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LEFT UPPER QUADRANT PAIN

	V	I	N	D
	Vascular	Inflammatory	Neoplasm	Degenerative
				and Deficiency
Abdominal Wall	Ruptured vein	Cellulitis	Metastatic carcinoma of ribs
Spleen	Infarct Aneurysm	Infectious mononucleosis Subacute bacterial endocarditis	Leukemia Hodgkin lymphoma
Stomach		Gastritis Gastric ulcer	Gastric carcinoma
Colon	Mesenteric thrombosis	Diverticulitis Mucous colitis Parasites	Colon carcinoma
Pancreas		Pancreatitis	Pancreatic carcinoma Pancreatic cyst
Adrenal Gland	Infarct		Malignancy with infarction
Kidney	Embolism Infarction	Pyelonephritis Perinephric abscess	Hypernephroma
Aorta	Atherosclerotic aneurysm			Medionecrosis with dissecting aneurysm
Spine		Tuberculosis of the spine Tabes dorsalis	Myeloma Metastatic carcinoma Spinal cord tumor	Osteoarthritis

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Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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