Spleen pain stems from anything that stretches, inflames, or damages the organ, and the list of culprits is longer than most people expect. Blunt trauma is the classic trigger, but infections like mononucleosis, blood clots that cut off blood flow, blood disorders, liver disease, autoimmune conditions, and even rare structural quirks can all produce pain in or around the spleen. Because the spleen sits quietly in the left upper abdomen and rarely draws attention when healthy, pain in that area often catches people off guard and can mimic other conditions entirely.
Where Spleen Pain Actually Shows Up
The spleen tucks under the lower left ribs, roughly at the level of your ninth through eleventh ribs on the left side. When something goes wrong with it, the most common complaint is pain or tenderness in the left upper quadrant of the abdomen. A study tracking splenic infarction cases over ten years found that about 85% of patients who had pain felt it in the left upper abdomen or the upper-middle abdomen just below the breastbone.1PubMed Central. Acute Splenic Infarction at an Academic General Hospital Over 10 Years: Presentation, Etiology, and Outcome But spleen problems do not always announce themselves in the obvious spot.
One of the most distinctive features of spleen-related pain is that it can show up in the left shoulder instead of the abdomen. This is called Kehr’s sign, named after a German surgeon from the early 1900s. It happens because an irritated or bleeding spleen aggravates the diaphragm sitting just above it, and the nerve serving the diaphragm (the phrenic nerve) shares a pathway with nerves that supply the shoulder area. Your brain misreads the signal as shoulder pain.2PubMed. Traditional Kehr’s sign: Left shoulder pain related to splenic abscess This referred pain pattern can confuse both patients and clinicians, since left shoulder pain more commonly points to musculoskeletal issues or heart problems. In cases of splenic injury or rupture, pressing on the left upper abdomen can trigger or worsen this shoulder pain.3PubMed Central. Epstein-Barr Virus-Associated Atraumatic Spleen Laceration Presenting with Neck and Shoulder Pain
Worth noting: roughly one in six people with splenic infarction had no abdominal pain at all, presenting instead with fever, nausea, or other vague symptoms.1PubMed Central. Acute Splenic Infarction at an Academic General Hospital Over 10 Years: Presentation, Etiology, and Outcome So spleen problems do not always mean spleen pain, which is part of what makes them tricky to catch.
Trauma and Physical Injury
The spleen is the organ most commonly injured in blunt abdominal trauma, whether from car accidents, sports collisions, or falls.4The Journal of Emergency Medicine. Splenic injury after blunt abdominal trauma: an unusual presentation Its position under the ribs gives it some protection, but a hard enough blow to the left side or upper abdomen can lacerate or rupture it. Pain from traumatic splenic injury ranges from a dull ache in the left upper abdomen to sudden, severe pain that spreads across the entire belly, depending on the severity of the injury and how much internal bleeding occurs.
What makes splenic trauma especially dangerous is that symptoms can be delayed. A case report describes a patient who appeared stable enough to be sent home after a fall, only to return the next day with dizziness and dangerously low blood counts from a ruptured spleen that required emergency surgery.5PubMed Central. Close Call After a Fall: Understanding Traumatic and Atraumatic Splenic Rupture and Its Life-Threatening Consequences A spleen can crack or bleed slowly at first, with blood pooling around the organ before the capsule gives way entirely. This is why anyone who takes a significant hit to the abdomen should watch for worsening pain, lightheadedness, or a rapid heartbeat in the hours and days that follow.
Infections That Target the Spleen
The spleen filters blood and traps bacteria, which means infections can hit it hard. The two main infection-related problems are spleen enlargement and, in extreme cases, splenic abscess or rupture.
Infectious mononucleosis, the illness caused by the Epstein-Barr virus, is probably the best-known infection linked to spleen trouble. Mono causes the spleen to swell in most patients, and while it usually resolves on its own, a small fraction of people develop a genuinely dangerous complication: the enlarged spleen tears. Splenic rupture occurs in roughly 0.1% to 0.5% of mono patients, and it happens more often in males. Pain may be diffuse and hard to pin down rather than sharply localized to the left side, and some patients feel it as chest pain or nausea rather than classic abdominal pain.6PubMed Central. Splenic Rupture in Infectious Mononucleosis: A Case Report This is why doctors tell people with mono to avoid contact sports and heavy lifting for several weeks. Determining exactly when it is safe to return to sports remains debated; ultrasound can check spleen size, but because people’s spleens vary in baseline size, imaging alone does not always give a clear green light.7PubMed Central. Return to Play After Infectious Mononucleosis Athletes in contact sports who want to return sooner than the standard waiting period may use imaging to help gauge whether the spleen has returned to normal dimensions.8PubMed. Determination of safe return to play for athletes recovering from infectious mononucleosis: a review of the literature
Splenic abscess, a pocket of pus within the spleen, is another infectious complication. It can develop from bacterial infections that seed the spleen through the bloodstream, or as a secondary infection within a damaged area of the organ. Pain is usually in the left upper abdomen and can radiate to the left shoulder via the same referred-pain mechanism as other splenic injuries.2PubMed. Traditional Kehr’s sign: Left shoulder pain related to splenic abscess Fever, chills, and general malaise often accompany it.
Splenic Infarction
A splenic infarct happens when a blood clot or other blockage cuts off blood supply to part of the spleen, causing that tissue to die. It is one of those conditions that can produce intense, sharp left-sided pain that comes on suddenly, and it often gets mistaken for a heart attack, kidney stone, or pancreatitis at first.
The leading cause is cardiogenic emboli, meaning blood clots that form in the heart (often due to atrial fibrillation or valve disease) and travel to the spleen. In a ten-year review at one hospital, clots originating from the heart accounted for about 63% of all splenic infarction cases. Autoimmune diseases and infections each caused about 13%.1PubMed Central. Acute Splenic Infarction at an Academic General Hospital Over 10 Years: Presentation, Etiology, and Outcome People with conditions that make their blood prone to clotting, such as certain cancers, inherited clotting disorders, or sickle cell disease, face a higher risk as well.
The pain of a splenic infarct tends to be steady, located in the left upper abdomen, and it may worsen with deep breathing. Some patients also develop a low-grade fever. Small infarcts can resolve on their own with pain management and treatment of the underlying clotting problem, but large infarcts occasionally lead to abscess formation or rupture.
Blood Disorders and Cancers
The spleen plays a central role in filtering damaged or abnormal blood cells, so diseases that produce large numbers of abnormal cells can overwhelm and enlarge it. Sickle cell disease is a prime example. In a condition called acute splenic sequestration crisis, red blood cells suddenly pool inside the spleen, causing it to swell rapidly and the patient’s blood counts to plummet. A review of sixteen adult cases found that most patients presented with pain crisis, though only four of the sixteen specifically reported abdominal pain, suggesting the crisis can present with more generalized or body-wide symptoms.9PubMed. Acute Splenic Sequestration Crisis in Adult Sickle Cell Disease: A Report of 16 Cases
Blood cancers, including leukemia and lymphoma, are another significant cause of spleen enlargement and pain. The spleen can become massively swollen as malignant cells accumulate in it. In a literature review, 136 cases of splenic rupture tied to blood cancers were identified; acute leukemia and non-Hodgkin lymphoma were the most common culprits, followed by chronic myelogenous leukemia. Male sex, severe spleen enlargement, and chemotherapy were factors linked to a higher risk of rupture.10BioMed Central / World Journal of Emergency Surgery. Large B-cell lymphoma presenting as acute abdominal pain and spontaneous splenic rupture In some cases, acute abdominal pain from splenic rupture is the first sign that a blood cancer exists at all.
Liver Disease and Portal Hypertension
Chronic liver disease, particularly cirrhosis, has a ripple effect on the spleen. When the liver becomes scarred and stiff, blood flow through it backs up, raising pressure in the portal vein system that connects the digestive organs to the liver. This elevated pressure, called portal hypertension, forces blood to congest in the spleen, causing it to enlarge.11PubMed Central. The spleen in liver cirrhosis: revisiting an old enemy with novel targets The enlargement itself produces a dragging or aching sensation in the left upper abdomen, and in some people the swollen spleen becomes palpable below the rib cage.
Spleen enlargement in cirrhosis is not just a symptom; it carries real clinical weight. It is associated with a worse prognosis and reflects both passive congestion from backed-up blood flow and active immune changes within the splenic tissue.12PubMed. The Role of the Spleen in Portal Hypertension The enlarged spleen also tends to trap and destroy too many blood cells, leading to low platelet counts and anemia, a condition called hypersplenism. So someone with liver disease and left-sided abdominal discomfort along with easy bruising or fatigue may well be dealing with spleen-related complications.
Autoimmune Conditions
Several autoimmune diseases can involve the spleen, either by causing it to enlarge or by triggering secondary problems like abscess or infarction. Rheumatoid arthritis is a common example. An uncommon complication called Felty’s syndrome, which occurs in less than 1% of rheumatoid arthritis patients, features a combination of low white blood cell counts and an enlarged spleen.13PubMed. Gastrointestinal and hepatic manifestations of rheumatoid arthritis People with Felty’s syndrome can be at risk for splenic abscess formation.
Systemic lupus erythematosus (SLE) can also cause significant spleen enlargement. In some cases, the spleen swells enough that it can be mistaken for a malignant mass. Lupus patients and those with certain vasculitis conditions may also develop splenic abscess.14PubMed. Splenic involvement in rheumatic diseases Because autoimmune diseases also raise the risk of blood clots, they contribute to splenic infarction as well, as noted in the infarction data above.
Cysts, Growths, and Structural Quirks
Not every cause of spleen pain involves an aggressive disease process. Benign cysts in the spleen are relatively rare and often found by accident during imaging done for another reason. Small cysts typically produce no symptoms at all, but as they grow they can stretch the splenic capsule and cause a vague, persistent abdominal ache. One case report describes a teenager who lived with two years of vague abdominal pain before a splenic cyst was finally identified as the cause.15PubMed Central. A 14-year girl with abdominal pain: case report of splenic cyst Splenic hemangiomas, which are tangles of blood vessels within the organ, are another benign finding that can occasionally produce symptoms.16PubMed. Hemangioma of the spleen: presentation, diagnosis, and management
Then there are the structural oddities. A “wandering spleen” occurs when the ligaments that normally hold the spleen in place are loose or absent, allowing the organ to drift around the abdomen. The danger is torsion: the spleen twists on its blood supply, producing sudden, severe abdominal pain that mimics a surgical emergency. Patients with a wandering spleen may have a history of intermittent, unexplained belly pain from the spleen twisting and then untwisting on its own.17PubMed Central. Torsion of a wandering spleen: A rare cause of acute abdomen
Accessory spleens, small extra nodules of splenic tissue, are present in roughly 10% to 30% of people and are almost always harmless. Rarely, though, an accessory spleen can undergo torsion, infarction, or rupture, causing acute abdominal pain that can mimic appendicitis, pancreatitis, or bowel ischemia.18PubMed Central. Accessory spleen torsion: a hidden etiology of acute abdominal emergency Because these tiny extra spleens are not on most clinicians’ radar, the diagnosis is often made only after imaging or even surgery.19International Journal of Surgery Case Reports. Accessory splenic infarction presenting as acute abdominal pain: A case report
Rare Metabolic Causes
Occasionally, massive spleen enlargement and associated discomfort stem from metabolic storage disorders that most physicians encounter only a handful of times in a career. Gaucher disease, a genetic condition in which a missing enzyme causes fatty substances to accumulate in certain immune cells, is one of the few disorders that can produce truly massive spleen enlargement. Identifying Gaucher disease matters because treating the underlying enzyme deficiency can reverse the spleen problems, and an unnecessary splenectomy could actually be harmful.20PubMed Central. Gaucher Disease: One of the Few Causes of Massive Splenomegaly If common causes of a very large spleen have been ruled out and the patient is young, storage diseases like this one deserve consideration.
How Spleen Problems Are Diagnosed
The spleen has been called “the forgotten organ” in radiology, partly because it tends to be overshadowed by its neighbors, the liver and kidneys, even though it shows up clearly on standard abdominal imaging.21PubMed Central. Imaging of the spleen: what the clinician needs to know Ultrasound and CT are the two primary tools. In one comparison, ultrasound detected splenic abnormalities in about 98% of cases, compared with roughly 80% for CT, and ultrasound was more sensitive at picking up malignant lesions like lymphoma.22Acta Radiologica. Ultrasound or CT in Splenic Diseases? CT with contrast tends to be better at characterizing the exact nature and extent of an abnormality, and it is the go-to tool when trauma or acute bleeding is suspected. MRI can help in complicated cases where CT and ultrasound leave questions unanswered.23PubMed. Radiology of the spleen
One complication in diagnosis is that different splenic problems often look similar on imaging. The appearance of a cyst, an infarct, and a tumor on a scan can overlap enough that additional tests or biopsy are sometimes needed to tell them apart.22Acta Radiologica. Ultrasound or CT in Splenic Diseases? Blood work also plays a role: a complete blood count can reveal abnormally low platelets or white cells that suggest the spleen is overactive, and markers for infection, autoimmune disease, or blood cancers help narrow the diagnosis.
When Spleen Pain Is an Emergency
Most causes of spleen pain are manageable, but a few scenarios require urgent attention. Splenic rupture, whether from trauma or from a spleen weakened by disease, is the most dangerous. Blood spilling into the abdominal cavity can cause life-threatening blood loss. Warning signs include sudden sharp left-sided abdominal pain, lightheadedness or fainting, confusion, rapid heartbeat, and pain that spreads to the left shoulder.5PubMed Central. Close Call After a Fall: Understanding Traumatic and Atraumatic Splenic Rupture and Its Life-Threatening Consequences Rupture can happen without any trauma at all in people with significantly enlarged spleens from infections, cancers, or other diseases.
Acute splenic sequestration in sickle cell patients is another emergency, since the rapid trapping of blood cells can cause severe anemia and circulatory shock within hours.9PubMed. Acute Splenic Sequestration Crisis in Adult Sickle Cell Disease: A Report of 16 Cases Torsion of a wandering spleen also demands prompt surgical intervention, because a twisted blood supply quickly kills the organ’s tissue. If you have known spleen enlargement from any cause and develop sudden worsening of abdominal pain, dizziness, or signs of shock, seek emergency care immediately.
What Happens When the Spleen Has to Come Out
Surgery to remove the spleen (splenectomy) remains a common treatment for severe trauma, certain blood disorders, and cases where the spleen is causing more harm than good. In recent years, there has been a trend toward preserving the spleen whenever possible, driven by growing awareness of what life without one entails.24PubMed. Benefits and risks of splenectomy
The spleen is a key player in fighting certain bacterial infections, particularly from encapsulated organisms like pneumococcus and meningococcus. Without it, you face a lifelong elevated risk of a devastating condition called overwhelming post-splenectomy infection (OPSI), which can progress from mild flu-like symptoms to organ failure and death within hours.25PubMed Central. Post-splenectomy sepsis: preventative strategies, challenges, and solutions Even when splenectomy is done incidentally during another procedure, the risk of overwhelming infection is about 35 times higher than in the general population. The risk climbs further depending on why the spleen was removed, with blood disorders like thalassemia and portal hypertension carrying some of the highest infection risks.26PubMed. Asplenic-hyposplenic overwhelming sepsis: postsplenectomy sepsis revisited
People who have had their spleen removed need vaccinations against pneumococcus, meningococcus, and Haemophilus influenzae type b, along with a plan for rapid antibiotic treatment at the first sign of any febrile illness. Many carry a medical alert card or bracelet. It is a manageable situation, but it requires vigilance for the rest of your life, which is a large part of why surgeons increasingly try to save the spleen rather than take it out.