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Left upper quadrant abdominal pain in the ED

Left upper quadrant pain:

differential diagnosis:

  • essentially as for epigastric pain but makes diagnoses of biliary disease or appendicitis much less likely
  • gastritis
  • as for RUQ pain such as:
  • focal tenderness over the descending colon in the absence of renal pathology:
  • splenic rupture - this may be rapidly fatal
    • usually post-trauma
    • higher risk in those with splenomegaly
  • splenic infarct
    • rare cause of abdominal pain and may be the result of arterial or venous occlusion
    • often is the presenting complaint of an underlying condition
    • usually in a person with an underlying hematologic disorder (eg. sickle cell disease (SCD)), hypercoagulable state, blood-borne malignancy causing splenomegaly, blunt abdominal trauma, pancreatitis, compressive pancreatic masses, or embolic illness.
    • 1/3rd have splenomegaly; 1/3rd have a fever; over half have a raised WCC; over 2/3rds have raised LDH;
  • splenic artery aneurysm with distended thin wall and impending rupture
    • rare, but a condition to consider in 2nd or 3rd TM of pregnancy, portal hypertension, liver transplant, pancreatitis, hypertension, atherosclerosis, Marfans, trauma, large vessel vasculitis, etc
    • prevalence of splenic artery aneurysm is 0.04% to 0.10% at arteriography and autopsy
    • 78% are in women 1)
      • 50% of those that occur in pregnant women will rupture during pregnancy! Two-thirds of SAA rupture in the third trimester and typically in the last two weeks of pregnancy. 2)
    • accounts for about 60% of visceral arterial aneurysms (remainder are mainly renal artery aneurysms)
    • may present with episodic LUQ pains often lasting 24hrs +/- radiation to L shoulder
    • may be detected as a cystic mass near the pancreas on US if not obese, or CTKUB
    • early diagnosis with contrast CT is critical to manage prior to rupture
    • risk of rupture is 2% to 10% (much higher in pregnant patients)
    • intervention prior to rupture is usually recommended if either:
      • aneurysm size larger than 2 or 2.5 cm
      • growth of the aneurysm by 3 to 5 mm or more during surveillance regardless of initial size
      • symptomatic
      • women of childbearing age
      • portal hypertension
      • planned liver transplant
    • mortality of intervention options is said to be ~1% 3)
      • complications of intervention include postembolization syndrome, splenic infarction or abscess, and pancreatitis
  • ruptured splenic artery aneurysm - this may be rapidly fatal mortality is over 25% (maternal mortality due to SAA rupture increases up to 75%, and fetal mortality increases as high as 95%)
    • usually present in hypovolaemic shock with abdominal or chest pain and positive FAST US (DDx ruptured ectopic or spleen), but may also have haematuria
    • patients in shock needing massive blood transfusion to keep alive should probably go straight to theatre for surgical intervention rather than radiologic intervention
  • ruptured left renal artery aneurysm
    • these are rare (0.1% of the population in autopsy studies), usually present in hypovolaemic shock with abdominal pain, but may also have haematuria or urinary obstruction
    • rupture occurs in 3-5% with these aneurysms and has a 10% mortality, thus rupture prevalence and mortality rates are much lower than with splenic artery aneurysms
    • mainly in those over 60yrs, 90% have hypertension
    • most younger patients are women and two-thirds have fibromuscular dysplasia 4)
    • indications for intervention for non-ruptured renal artery aneurysm:
      • size > 2cm
      • symptoms
      • refractory hypertension with significant renal artery stenosis or thromboembolism
      • women in childbearing age
abdopain_luq.txt · Last modified: 2022/08/06 01:14 by wh

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