Pain Under Left Rib Cage & Abdominal Diseases: Causes, Treatment, Diagnosis

1. Esophagitis
2. Gastritis
3. Gastric Ulcer
4. Acid Reflux or GERD
5. Gas in Colon (Splenic Flexure Syndrome)
6. Spleen Irritation
7. Irritable bowel syndrome,
8. Post-surgical Adhesions and
9. Food Intolerances and
10. Peritonitis

The rib cage supports and protects vital organs in the thoracic cavity as well as upper abdominal cavity below the diaphragm. The pain on left side of chest is often mistaken for pain caused by heart diseases.¹ The lower left rib cage covers part of upper left abdominal quadrant. Pain localized over left lower rib cage is frequently caused by diseases of abdominal organs like spleen, lower end of esophagus, stomach, peritoneum, mesentery and intestine. We will discuss diseases of upper left abdominal viscera that causes pain over left upper abdomen and left lower rib cage.

1. Pain Under Left Rib Cage Caused Due to Esophagitis

   Sometimes, long standing acid reflux or irritation of the stomach lining causes esophagitis. Esophagitis causes sharp pain under the left rib cage; especially after consumption of food. Such pain is described as non-cardiac pain.¹ The pain caused by esophagitis occasionally refer to the left shoulder or under the breastbone.

   Symptoms of Esophagitis

   • Mid lower sternal pain refers to left side rib cage. Pain intensity increases 1 to 2 hours after consumption of food.
   • Belching
   • Nausea

   Investigation

   Esophagoscopy– The procedure involves insertion of endoscope through mouth into esophagus under sedation. The endoscope camera shows the image of esophagus mucosa. The irritation of mucosa and ulcer is seen on large television screen.

   Barium X-Ray– Image taken following barium swallow shows esophageal mucosal erosion and ulcer.

   Treatment

   Antacid Medications– Antacids neutralizes stomach acid and prevents irritation of ulcer that helps to reduce intensity of pain. The ulcer healing is also promoted by less acid in the stomach content. Antacids are available over the counter in most pharmacies. The antacids most often used for treatment of peptic ulcers are: Alka-Seltzer, Milk of Magnesia, Maalox, Mylanta, Rolaids, Pepto-Bismol and Tums.

   H2 Blocker– H2 blocker blocks the H2 receptor. Stimulation of H2 receptor that lies in gastric mucosa causes increase secretion of hydrochloric acid. Hydrochloric acid is secreted by proton pump that lies within stomach mucosa. Blocking of H2 receptor prevents activation of proton pump and thus production of hydrochloric acid stops. H2 blockers prescribed are Nizatidine, Pepcid and Tagamet.

   Proton Pump Blocker– Few medication bypasses the H2 receptors and directly block proton pump. The blocking of proton pump stops acid secretion. Proton pump blocker prescribed are : Prilosec, Prevacid and Protonix.

2. Pain Under Left Rib Cage Caused Due to Gastritis

   The inflammation of gastric mucosa is known as gastritis. Gastritis is observed following food poisoning and infection. Infection is caused by bacteria and viruses. Stomach bacterial infection is frequently caused by staphylococcus aureus and streptococcus bacteria. Similarly, virus infection is caused by rotavirus. Most cases of gastritis are associated with H. Pylori bacterial infection.² Gastritis is also caused by anti-inflammatory medications (NSAIDs).³

   Symptoms-

   • Chronic pain– Chronic burning pain is felt under left rib cage and left upper abdomen. Pain become severe after consumption of food.
   • Nausea
   • Vomiting
   • Abdominal bloating

   Investigation

   • Gastroscopy– Gastroscopy is a procedure performed under sedation. The procedure helps to observe magnified image of stomach mucosa. Gastroscopy is performed by using endoscope. Endoscope is a long flexible tube that holds at the tip a high definition camera. Diameter of the endoscope is between 2 to 10 mm. The endoscope is inserted into stomach through mouth under sedation. The image of esophagus and stomach is observed over television screen. The gastritis is diagnosed when inflammation of stomach mucosa is observed.
   • Blood Test for H. Pylori- The blood test is performed to detect antibodies against H. Pylori.²
   • Urea Breath Test- The test shows increased level of carbon di oxide in exhaled air. Individual suffering with gastritis is advised to swallow tablets of urea. The enzyme urease produced by H. Pylori bacteria breaks down the urea into ammonia and carbon dioxide. The carbon di oxide then gets absorbed by blood and release into exhaled air by lungs.
   • Gastric Biopsy- Gastric biopsy is often added procedure during gastroscopy. During gastroscopy procedure, the tiny piece of stomach mucosa is removed. The procedure is known as biopsy. The sample of mucosa then examined under microscope.

   Treatment

   • Antacid Medications- Alka-Seltzer, Milk of Magnesia, Maalox, Mylanta, Rolaids, Pepto-Bismol and Tums.
   • H2 Blocker- Nizatidine, Pepcid and Tagamet.
   • Proton Pump Blocker- Prilosec, Prevacid and Protonix.
   • Antibiotics- If the H. Pylori bacteria are found in gastric mucosa then individual suffering with gastritis is treated with antibiotics for 7 to 10 days. Most effective antibiotics against H. Pylori infection are amoxicillin, tetracycline and metronidazole.

3. Pain Under Left Rib Cage Caused Due to Gastric Ulcer

   Stomach is the first large tube that holds the food and breaks down food particles into smallest particles. The food is mixed with gastric juice. Gastric juice contains large quantity of hydrochloric acid. Hydrochloric acid is secreted by proton pump located within stomach mucosal membrane. The stomach mucosal epithelial cells are resistant to harmful effects of acid. In few cases the resistance is lost because of decreased mucosal secretion, anxiety, presence of H. Pylori bacteria in stomach and excessive secretion of acid. The epithelium layer of gastric mucosa slowly gets eroded in several area. The deeper layer of mucosa become sensitive. The eroded mucosa is known as ulcer and ulcer become painful, when acid concentration is increased in stomach juice.

   Symptoms-

   • Left lower rib cage and left upper abdominal pain.
   • Abdominal bloating
   • Nausea
   • Vomiting
   • Weight loss

   Investigation

   • Gastroscopy
   • Blood Test for H. Pylori
   • Urea Breath test

   Treatment

   • Antacid Medications- Maalox, Mylanta Pepto-bismol and Tums.
   • H2 Blocker- Tagamet, Zantac, Nizatidine and Pepcid.
   • Proton pump blocker- Prilosec, Prevacid and Protonix.

   Surgery⁴–

   • Truncal vagotomy-antrectomy,
   • Proximal gastric vagotomy.
   • Proximal gastric vagotomy or
   • Truncal vagotomy-pyloroplasty

4. Acid Reflux or GERD As A Cause Of Pain Under Left Rib Cage-

   Stomach food content is pushed in to duodenum when gastric sphincter opens. The gastric juice containing digested food also pushed upward towards esophagus. The passage of food into esophagus is prevented by close gastroesophageal sphincter. In few cases the gastroesophageal sphincter become weak and then gastric juice passes into lower section of esophagus. The gastric juice occasionally is pushed into mouth and individual feels acidic taste. The condition is known as belching. The acidic gastric juice causes irritation of esophageal mucosa that results in mucosal erosion and formation of ulcer. The condition then is known as Gastroesophageal reflux disease (GERD).

   Symptoms-

   • Chronic Pain- Pain is felt at epigastrium and left lower rib cage. Burning pain is also known as heartburn.
   • Regurgitation of Food- The stomach juice containing food regurgitate into esophagus and mouth. Individual feels sour taste of food.
   • Sore Throat– The acidic regurgitated food irritates the mouth and pharynx that results in sore throat.
   • Dyspepsia– Difficulties in swallowing
   • Bad Breath

   Investigation-

   • Endoscopy (Esophagoscopy)- Check the esophageal mucosa with endoscope
   • Esophageal manometry- Check esophageal muscle contraction and pressure.

   Treatment

   • Antacid medications- Maalox, Mylanta Pepto-bismol and tums.
   • H2 Blocker- Tagamet, Zantac, Nizatidine and Pepcid.
   • Proton pump blocker- Prilosec, Prevacid and Protonix.

   Surgery-

   • Fundoplication
   • LINX device implant

5. Gas in Colon (Splenic Flexure Syndrome): Cause of Pain Under Left Rib Cage

   Excessive amount of gas is formed in large colon when fatty food is frequently consumed. The gas gets trapped in section of large intestine known as splenic flexure.

   Splenic flexure is the junction between transverse colon and descending colon that lies next to spleen on left side. Splenic flexure lies below the left rib cage. The trapped gas causes pain and discomfort under left rib cage.

   Symptoms-

   • Left rib cage pain
   • Distended abdomen on left upper abdomen,
   • Flatulence

   Investigation

   • Abdominal X-Ray– The images shows the shadow of gas in the splenic flexure.
   • Barium X-Ray- Individual suffering with left rib cage pain is advised barium swallow test. Multiple X-Rays are taken after barium is taken by mouth. Multiple X-Ray are taken to observe the images of large colon.
   • CT Scan– The CT scan is performed after individual is either asked to swallow dye or given enema of dye. The CT scan shows the presence of scan in CT scan images.

   Treatment

   Preventive Treatment-

   • Eat less fatty food
   • Eat small portion multiple time
   • Avoid chewing gum
   • Avoid smoking
   • Regular exercise
   • Diet Control
   • High fiber diet
   • Avoid dairy food
   • Decrease amount of sugar intake
   • Drink lots of water
   • Fiber Supplement
   • Metamucil
   • Oatmeal
   • Barley

   Medication-

   • Activated charcoal
   • Pepto-Bismol
   • Simethicone
   • Lactose enzyme

6. Pain Under Left Rib Cage Caused Due to Spleen Irritation (Enlarged Spleen)

   The enlarged spleen stretches the peritoneal covering. The enlarged spleen then become irritated and causes pain. The pain is felt over left side of rib cage since spleen lies under the diaphragm on left side. Under normal circumstances the pain subsides after rest and stopping of physical activity. Enlarged spleen is caused by infection, cancer and autoimmune disease.⁵ Infection that causes splenomegaly are mononucleosis, and toxoplasmosis. Cancer such as leukemia and lymphoma often causes splenomegaly.

   Symptoms

   • Chronic Pain- Pain is felt on left side of lower rib cage.
   • Weight loss
   • Weakness and fatigue
   • Fever
   • Nausea and vomiting
   • Abdominal distension
   • Hiccup caused by irritation of diaphragm

   Investigation

   • CT- Scan- Image of enlarge spleen is seen on CT scan.
   • MRI– Image of enlarge spleen is seen on Magnetic resonance imaging.
   • Ultrasound– Image of enlarge spleen is seen on ultrasound examination.

   Treatment

   Pain Medication-

   • Tylenol
   • Opioid Medication- Hydrocodone, Oxycodone and Morphine
   • Splenectomy- Spleen is surgically removed.

7. Pain Under Left Rib Cage Caused Due to Irritable Bowel Syndrome

   Cause of irritable bowel syndrome is unknown. Anxiety, depression and genetic imbalance of bowel nerve stimulation is considered as a cause of irritable bowel disease. The diseases like anxiety and depression causes malfunction of signal transmission from brain to intestine. The inflammatory disease is mostly observed in large intestine. The pain is localized over left rib cage when disease is predominantly observed in splenic flexure of large intestine.

   Symptoms

   Chronic pain- pain is predominantly observed in left rib cage pain.

   • Diarrhea
   • Vomiting
   • Abdominal Distension
   • Mucus in stool

   Investigation

   • Blood examination- Results of blood examination suggests absence of infection or presence of cancer.
   • Stool examination- Stool examination shows absence of bacteria and viruses as a cause of infection.
   • Lactose intolerance test- negative
   • CT Scan and MRI- Images shows absence of signs of cancer.
   • Biopsy- Biopsy shows the signs of mucosal inflammation.
   • Colonoscopy- Examination shows inflamed bowl and absence of cancer.

   Treatment

   Diet-

   • High fiber diet,
   • Avoid food that causes increased bowel movement.
   • Avoid daily food
   • Avid food containing gluten
   • Fluid- Drink lots of fluid. Avoid carbonated fluid.
   • Antidiarrheal medications- Cholestyramine and cholesterol.
   • Anti-spasmodic Medication- Dicyclomine
   • Tricyclic antidepressant- Tofranil and Pamelor
   • Selective Serotonin reuptake inhibitor- Prozac and Paxil
   • Pain medication- Tylenol, Lyrica and Neurontin
   • Bowel movement inhibitor- Lotronex
   • Prophylactic antibiotic- Lubiprostone is prescribed to prevent bacterial infection in patient suffering with frequent diarrhea.

8. Post-surgical Adhesions As a Cause of Pain Under Left Rib Cage

   Open abdominal surgery is known as laparotomy. Laparotomy surgery is performed to remove cancer of pancreas, stomach and intestine. Laparotomy surgery is also performed to remove enlarged spleen. Surgical treatment of bleeding gastric ulcer includes vagotomy and pyloroplasty. Laparotomy surgery of viscera that lies close to upper left abdomen forms post-surgical scar tissue within skin, subcutaneous tissue, muscles, peritoneum and mesentery. The scarring of tissue that lies within left upper abdomen causes referred pain under left lower rib cage.

   Symptoms-

   • Chronic pain- Pain is felt over left upper abdomen and behind lower rib cage.
   • Nausea and vomiting- These symptoms are caused by severe pain or partial obstruction of stomach and intestine and stomach.
   • Fever- Inflammation and infection of scar tissue causes fever.

   Investigation

   • Blood examination- Increase white blood cell count suggest infection.
   • Laparoscopy- Laparoscopic examination helps to see the scar tissue.
   • MRI and CT Scan- Images of radiological studies shows the scar tissue and shift of viscera.

   Treatment

   • Pain Medication-
   • Tylenol- Mild to moderate pain is treated with tylenol.
   • NSAIDs- Anti-inflammatory medications are prescribed for burning pain during initial phase immediately after surgery.
   • Opioids- Severe pain is treated with opioids. Opioid prescription is also preferred for 1 to 2 weeks immediately after surgery.
   • Physical Therapy– Physical therapy and stretching exercises are tried to stretch the scar tissue to prevent the visceral and mesentery pull.
   • Antibiotics- Individual suffering with fever is treated with antibiotics.
   • Surgery- Surgery is recommended when all other treatment fails. Surgery is performed to remove scar tissue and adhesions. Surgery helps to relieve the twist and partial obstruction of viscera.

9. Food Intolerance

   Food intolerance is not same as food allergies. Food intolerance is caused by consumption of old rotten food and also consumption of excessive amount of food. Old rotten food contains degraded food that is preserved in room temperature for long time. Some of the food not frozen or stored in refrigerator is contaminated with bacteria and viruses. The bacteria and viruses often produces toxins that is mixed in food. Toxins causes food poisoning and intolerance.

   Investigation for food intolerance

   Peanut allergy is the most serious food allergy and intolerance. The other food that can cause food intolerance are dairy food, gluten and fructose containing food.

   Following test are performed to evaluate food intolerance-

   1. Blood allergy test- The investigation involves allergy test. The blood sample of child or adults are tested for several food allergies.
   2. Check level of serum IgE antibodies
   3. Lactose intolerance test
   4. Gluten sensitivity test

   Treatment of Food Intolerance

   1. Avoid Certain Food- Intolerance or allergies to peanut and animal protein often is difficult to treat. Food allergy is lot serious condition than food intolerance. Peanut allergy can cause serious complication. In such cases food that causes intolerance because of food allergy must be strictly avoided.
   2. Allergy Shots- The intolerance to gluten and lactose is often treated with series of injection containing gluten and lactose in very small amount. Eventually child develops tolerance and able to consume gluten and lactose with no intolerance
   3. Gas in Stomach and Intestine- Take few pills of Tums that may help to absorb gas.
   4. Abdominal Pain- Severe abdominal pain is treated with antispasmodics like belladonna.

   Symptoms-

   • Lower thoracic and upper left abdominal pain.
   • Nausea and vomiting
   • Diarrhea
   • Abdominal bloating

   Investigation

   • Treatment

• Peritonitis-

  Peritoneum is formed by serous membrane, medothelium and thin layer of connective tissue. Peritoneum is identified as parietal and visceral peritoneum. The parietal peritoneum covers inside of abdominal muscle and visceral peritoneum covers outer surface of all abdominal organs. The peritoneal fold within abdominal cavity holds blood vessels, lymphatic vessels and nerve. The peritoneal fold is known as mesentery. Inflammation of parietal and visceral peritoneum is known as peritonitis. Inflammation or injury of peritoneum that covers stomach, diaphragm and inner surface left upper abdomen skeletal muscles causes pain that is spread under left lower rib or upper left quadrant of abdomen. The inflammation or infection of peritoneum that lies on left upper abdomen causes pain underneath the left rib cage. Peritonitis is caused by bacterial or fungal infection. Infection of peritoneum is common in patient undergoing repeated procedure like peritoneal dialysis. Peritonitis follows rupture appendix and perforated peptic ulcer. The other causes of peritonitis are diverticulitis and abdominal penetrating injury.

  Symptoms

  • Pain
  • Fever
  • Nausea and vomiting
  • Hiccough
  • Chills
  • Abdominal bloating
  • Feeling weak and fatigue
  • Loss of appetite

  Investigation

  • Blood Examination- White blood cell count is high
  • Radio-Imaging Studies- X-Ray, CT Scan and MRI images are examined to rule out cancer growth and perforation.
  • Peritoneal Fluid Studies- Bacterial culture and slide is observed for bacterial cause of peritonitis.

  Treatment

  • Antibiotics- Peritonitis caused by bacterial infection is treated with antibiotics. The choice of antibiotics depends on type of bacteria causing infection and antibiotic sensitivity test.
  • IV Fluid- Most patient suffer with dehydration because of prolonged disease that causes loss of appetite, nausea, vomiting and difficulties to eat as well as drink.
  • Dehydration is treated with intravenous fluid.
  • Pain Medication- Mild to moderate pain is treated with Tylenol and severe pain is treated with opioids.
  • NSAIDs- Inflammation of peritoneum caused by traumatic peritonitis is treated with anti-inflammatory medications.
  • Surgery- The diseases like appendicitis and perforated peptic ulcer resulting in peritonitis is treated with surgery.
  • Physical therapy- Physical therapy is recommended once the infection is control. Physical therapy helps to rebuild the muscles and generalized weakness.

  References:

  1. Non-Cardiac Chest Pain.
     Frieling T¹., Visc Med. 2018 Apr;34(2):92-96.
  2. Treatment of Helicobacter pylori gastritis improves dyspeptic symptoms in children.
     Uc A¹, Chong SK., J Pediatr Gastroenterol Nutr. 2002 Mar;34(3):281-5.
  3. Ibuprofen, a Potential Cause of Acute Hemorrhagic Gastritis in Children – A Case Report.
     Mărginean MO^1,2, Meliț LE^1,2, Mocanu S³, Săsăran V²., J Crit Care Med (Targu Mures). 2018 Oct 1;4(4):143-146.
  4. Surgical treatment of peptic ulcer disease.
     Sachdeva AK¹, Zaren HA, Sigel B., Med Clin North Am. 1991 Jul;75(4):999-1012.
  5. Steroid-Refractory Autoimmune Hemolytic Anemia with Massive Splenomegaly.
     Ureshino H¹, Miyahara M²., Am J Med. 2017 Sep;130(9):e393-e394.

  Also Read:

  • Pain Under Left Rib Cage: Causes, Diagnosis, Treatment
  • Which Chest Diseases or Illnesses Causes Pain Under Left Rib Cage?
  • Rib Pain Due to Coughing: Causes and Medical Management