Recommended Imaging for Left Upper Quadrant Pain

Initial Imaging Approach

The American College of Radiology recommends CT of the abdomen and pelvis with contrast media as the first-line imaging modality for left upper quadrant (LUQ) pain due to its high diagnostic accuracy and ability to detect a wide range of pathologies 1
CT provides superior diagnostic yield compared to plain radiography for detecting sources of abdominal pain 2
CT results can change the leading diagnosis in up to 51% of patients and management decisions in 25% of patients with abdominal pain 2, 3

For suspected gallbladder pathology that may refer to LUQ, ultrasound has 81% sensitivity and 83% specificity for acute cholecystitis, and is recommended as the initial imaging modality 3
In pregnant patients or young patients where radiation exposure is a concern, ultrasound is recommended as the initial imaging modality 1
For premenopausal women when gynecologic pathology is suspected, ultrasound is recommended as the initial imaging modality 4
When IV contrast is contraindicated, unenhanced CT is recommended 5
For suspected urolithiasis, unenhanced CT has sensitivity and specificity near 100% 5
In elderly patients (≥75 years), unenhanced CT has similar accuracy to contrast-enhanced CT for acute abdominal pain 5

Acute pancreatitis typically requires CT for severity assessment and detection of complications, with the American College of Radiology recommending contrast-enhanced CT 1, 6
Renal pathology including pyelonephritis and nephrolithiasis can be evaluated with CT, which provides high diagnostic accuracy 1
Intestinal pathology such as colitis or diverticulitis extending to the LUQ can be evaluated with CT, which provides high diagnostic accuracy 4

Plain radiography has limited utility for LUQ pain due to low sensitivity, though it may detect pneumoperitoneum or bowel obstruction, according to the American College of Radiology 2, 5
Fluoroscopic contrast enema is not recommended as initial imaging for LUQ pain, as stated by the American College of Radiology 7
MRI is not recommended for initial evaluation of acute LUQ pain due to longer acquisition time, less sensitivity for extraluminal air, motion artifacts in symptomatic patients, and need for screening for contraindications, as recommended by the American College of Radiology 5, 7

The American College of Radiology recommends considering the patient's age, sex, and clinical presentation when selecting imaging modality 1, 4
CT with IV contrast improves detection of bowel wall pathology, pericolic abnormalities, vascular pathology, and intraabdominal fluid collections, as stated by the American College of Radiology 5
Laboratory tests should guide but not replace appropriate imaging studies when clinically indicated, according to the American College of Radiology 6

Relying solely on plain radiographs which have poor sensitivity for most causes of LUQ pain, as warned by the American College of Radiology 2
Failing to use contrast enhancement when evaluating for vascular pathologies or abscesses, as cautioned by the American College of Radiology 5
Delaying appropriate imaging in elderly patients who may present with atypical symptoms and normal laboratory values, as advised by the American College of Radiology 2