abdopain_luq
Left upper quadrant abdominal pain in the ED
- read this first abdominal pain in ED
- see also:
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:
- LLL pneumonia
- radicular pain from a thoracic spine issue such as discitis, osteomyelitis, tuberculosis (TB), crush fracture
- may be bilateral!
- focal tenderness over the descending colon in the absence of renal pathology:
- complication of colorectal cancer (bowel cancer)
- epiploic appendagitis of the fat adjacent the colon
- splenomegaly (not usually painful but can cause discomfort and tenderness)
- 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