Pain in the left hypochondrium

Specialty: Gastrointestinal.

• Left subcostal pain
• left upper abdominal quadrant pain
• splenalgia

Why it occurs

• Splenic infarction due to embolic occlusion of the splenic artery (common in patients with atrial fibrillation or endocarditis)
• Acute painful splenomegaly secondary to infectious mononucleosis or other viral/lymphoproliferative infections
• Pancreatitis of the tail of the pancreas with local inflammatory involvement
• Splenic flexure syndrome (accumulation of gas in the left colic flexure)
• Splenic abscess due to bacterial hematogenous dissemination.

Initial workup

Upper abdominal ultrasound (rapid study to evaluate spleen, collections or perisplenic free fluid) | CT of the abdomen with intravenous contrast in the arterial and portal phases (study of choice to document areas of wedge-shaped infarction, abscesses or neoplasia in the tail of the pancreas) | Complete blood count (leukocytosis or atypical lymphocytosis), blood cultures if there is suspicion of infection, PCR and coagulation profile | Electrocardiogram and transesophageal echocardiogram.

Standard management

• Controlled analgesia with opioids if pain due to splenic infarction is severe — IV fentanyl or morphine under strict monitoring of vital parameters
• Systemic anticoagulation or antiplatelet treatment if the origin is splenic arterial thromboembolism, once hemorrhage or splenic rupture has been categorically ruled out
• Directed intravenous antibiotic therapy in case of splenic abscess — ampicillin/sulbactam 3 g IV every 6 hours or meropenem 1 g IV every 8 hours
• Absolute and strict rest to avoid traumatic rupture of a congestive spleen (mononucleosis).