Pain in the left upper abdomen, sometimes radiating to the left shoulder, often traces back to the spleen when that organ is enlarged, inflamed, or injured. The spleen sits tucked under the lower ribs on your left side, so discomfort there can range from a dull ache to a sudden, sharp stab depending on what is going wrong. The causes span a wide spectrum, from common infections like mononucleosis to serious emergencies like splenic rupture, and some of them require immediate medical attention.
Where the Pain Actually Comes From
Your spleen is roughly the size of a fist and normally weighs only about 150 grams. It filters old blood cells, stores platelets, and helps fight certain bacteria. Because it is nestled against the diaphragm and stomach under the left ribcage, you generally cannot feel it from the outside unless it is enlarged. When the spleen swells, it stretches the capsule surrounding it, and that capsule is rich in nerve fibers. That stretching is the main reason spleen problems produce pain. The location of the pain is most often the left upper quadrant of the abdomen, sometimes described as “under the ribs on the left.” In about a third of cases involving splenic infarction, for example, the pain shows up in the upper middle of the abdomen near the stomach instead.
A hallmark that points toward the spleen rather than, say, a pulled muscle is pain that radiates up to the left shoulder. This phenomenon, called Kehr’s sign, happens because the diaphragm and the shoulder share nerve pathways. Blood or inflammation irritating the underside of the diaphragm can trick your brain into feeling shoulder pain. One case report documented a patient with Epstein-Barr virus who presented primarily with neck and shoulder pain, only for imaging to reveal a splenic laceration.1PubMed Central. Epstein-Barr Virus-Associated Atraumatic Spleen Laceration Presenting with Neck and Shoulder Pain
Infections That Enlarge or Damage the Spleen
Infectious mononucleosis, usually caused by the Epstein-Barr virus, is one of the most common reasons young adults end up with a tender, swollen spleen. The virus triggers the spleen to enlarge as it ramps up immune activity, and in roughly 0.1 to 0.5 percent of mono patients, that swelling leads to a splenic laceration or outright rupture, sometimes with surprisingly little trauma.1PubMed Central. Epstein-Barr Virus-Associated Atraumatic Spleen Laceration Presenting with Neck and Shoulder Pain That is why doctors tell you to avoid contact sports for weeks after a mono diagnosis. The spleen is temporarily fragile, and a blow to the abdomen during that window can be dangerous.
Other infections can settle directly in the spleen and form an abscess, which is a pocket of pus within the organ. This is uncommon but serious. In a case series of 16 patients with splenic abscess, fever was the most frequent symptom, appearing in about two-thirds of cases. Left upper quadrant pain or tenderness showed up in roughly a third, while half of the patients developed fluid around the left lung.2PubMed Central. Splenic Abscess: An Uncommon Entity with Potentially Life-Threatening Evolution The combination of fever with left-sided abdominal pain and a pleural effusion should raise suspicion for a splenic abscess, especially in people with weakened immune systems or endocarditis.
When the Blood Supply Gets Cut Off
A splenic infarction happens when blood flow to part of the spleen is blocked, usually by a clot. The tissue downstream of that clot dies, producing pain that can be sudden and severe or surprisingly subtle. A ten-year study at one hospital found that abdominal pain was the leading symptom, occurring in about 84 percent of patients with confirmed splenic infarction. The pain was most commonly in the left upper quadrant or epigastric area. But roughly one in six patients had no abdominal pain at all, which makes infarction easy to miss.3PubMed Central. Acute Splenic Infarction at an Academic General Hospital Over 10 Years: Presentation, Etiology, and Outcome
The underlying cause of splenic infarction is usually something that makes blood more likely to clot or slows blood flow through the spleen. Conditions that thicken the blood, atrial fibrillation that sends clots from the heart, and blood cancers that congest the spleen are all common culprits. One case report described a patient with polycythemia vera, a blood cancer that raises red blood cell counts, who developed severe left upper quadrant pain; imaging revealed two wedge-shaped areas of dead tissue in the spleen.4PubMed Central. Splenic infarction secondary to polycythemia Vera: Case report and literature review
Blood Disorders and Cancers
Several hematologic conditions can make the spleen painful, primarily by causing it to enlarge dramatically. Leukemias and lymphomas are among the more concerning causes. In a literature review of 136 cases of splenic rupture linked to blood cancers, acute leukemia and non-Hodgkin lymphoma were the most frequent culprits. Severe splenomegaly and chemotherapy were factors commonly associated with the rupture.5World Journal of Emergency Surgery. Large B-cell lymphoma presenting as acute abdominal pain and spontaneous splenic rupture; a case report and review of relevant literature Abdominal pain or a feeling of fullness in the left upper abdomen can occasionally be the first symptom that leads to a cancer diagnosis.
Sickle cell disease creates a different kind of threat. In young children with sickle cell disease, misshapen red blood cells can suddenly get trapped in the spleen in what is called an acute splenic sequestration crisis. The spleen rapidly swells as it fills with blood, which drains the child’s circulation and can lead to life-threatening collapse.6PubMed. Acute splenic sequestration crisis in sickle cell disease: early detection and treatment This complication is unpredictable and particularly dangerous in infants.7PubMed. Acute splenic sequestration crisis in sickle cell disease: cohort study of 190 paediatric patients Parents of children with sickle cell disease are often taught to feel for an enlarging spleen at home so they can seek help before shock sets in.
Liver Disease and Portal Hypertension
People with chronic liver disease, especially cirrhosis, frequently develop an enlarged, painful spleen as a downstream effect. When the liver becomes scarred and stiff, blood backs up in the portal vein, the major vessel running from the intestines and spleen to the liver. That back-pressure engorges the spleen. But the swelling is not purely passive congestion. The spleen’s own lymphoid tissue enlarges and becomes overactive, adding to the problem and worsening the portal hypertension in a kind of feedback loop.8PubMed. Role of spleen enlargement in cirrhosis with portal hypertension Splenomegaly in cirrhosis is associated with a poorer prognosis overall.9Journal of Nippon Medical School. The Role of the Spleen in Portal Hypertension
Autoimmune diseases can also involve the spleen. Systemic lupus erythematosus, for instance, affects the immune system broadly and is known to involve the organs that filter blood. In rare cases, lupus has caused spontaneous splenic rupture even without trauma.10PubMed Central. Systemic lupus erythaematosus presenting as spontaneous splenic rupture If you have a diagnosed autoimmune condition and develop new left upper quadrant pain, it is worth mentioning the possibility of splenic involvement to your doctor, even though it is uncommon.
Trauma and the Risk of Rupture
The spleen is one of the most frequently injured abdominal organs in blunt trauma. Car accidents, falls, and sports collisions account for the majority of cases, with blunt splenic injury making up roughly a quarter of all blunt abdominal trauma.11PubMed. Blunt splenic trauma: Assessment, management and outcomes The pain from a splenic injury can be immediate and severe, but delayed presentations are possible. One case report described a patient who arrived at the emergency department after what seemed like a minor fall, with imaging eventually revealing a serious splenic injury that required surgical removal of the organ.12PubMed. Splenic injury after blunt abdominal trauma: an unusual presentation
Spontaneous rupture, without any trauma at all, is rarer but does happen. A case report described a 56-year-old man with no trauma history who woke from sleep with sudden, severe left-sided abdominal pain. He had experienced two milder episodes in the preceding week. Within a short time his blood pressure plummeted and his heart rate surged, classic signs of internal bleeding.13PubMed Central. Spontaneous splenic rupture: A rare life-threatening condition; Diagnosed early and managed successfully Spontaneous rupture tends to occur when the spleen is already abnormal, whether from infection, cancer, or an inflammatory condition that has weakened it.
Splenic Artery Aneurysm, Especially in Pregnancy
A bulge in the splenic artery wall, known as a splenic artery aneurysm, can cause chronic left upper quadrant or epigastric pain and becomes truly dangerous if it ruptures. This condition carries particular risk during pregnancy. A systematic review found that rupture of a splenic artery aneurysm carries a mortality rate of about 25 percent in the general population, but that figure climbs to roughly 75 percent in pregnant women, with fetal mortality reaching 95 percent.14PubMed. Splenic artery aneurysms in pregnancy–a systematic review A pregnant person who develops sudden upper abdominal pain with or without signs of shock should be evaluated urgently, with ruptured splenic artery aneurysm on the differential.15PubMed Central. Rupture of Splenic Artery Aneurysm during Pregnancy: A Report of two Cases
When Left-Side Pain Is Not the Spleen
Not every ache under your left ribs is a spleen problem. The so-called side stitch you get while running after eating is one of the most familiar left-side pains, and research suggests it has nothing to do with the spleen. A study investigating exercise-related side pain found that the discomfort is more consistent with the fluid-filled gut tugging on the ligaments that anchor abdominal organs than with any change in splenic blood flow.16PubMed Central. Investigation of the side pain “stitch” induced by running after fluid ingestion Gas trapped in the splenic flexure of the colon, which sits right next to the spleen, is another frequent mimic. Costochondritis (inflammation of the cartilage connecting ribs to the breastbone), muscular strains, kidney stones, and even heart-related pain can all produce discomfort in the same general region. If the pain is clearly tied to meals, exercise, or certain body positions and resolves quickly, the spleen is less likely to be the cause.
How Doctors Investigate Spleen Pain
The spleen has been called “the forgotten organ” in radiology, partly because it is often overlooked on scans focused on the liver, kidneys, or bowel.17PubMed Central. Imaging of the spleen: what the clinician needs to know When a doctor suspects a splenic problem, the first step is usually an ultrasound or a CT scan. Ultrasound is noninvasive, cheap, and highly sensitive; one comparative study found it detected splenic lesions in about 98 percent of confirmed cases, outperforming CT in identifying malignant conditions like lymphoma. CT was better at picking up certain lesions like infarcts, particularly when contrast dye was used.18Acta Radiologica. Ultrasound or CT in Splenic Diseases? In practice, many patients get both: an ultrasound first for a quick look, followed by a CT scan if something abnormal turns up or if trauma is suspected.
Sometimes extensive testing still does not pin down a cause. Cases of isolated splenomegaly, where the spleen is enlarged but every lab and scan comes back without a clear explanation, are not rare and can be difficult to manage. Doctors may recommend monitoring over time, periodic imaging, and in some situations a biopsy or even removal of the spleen to get a tissue diagnosis.
Treatment Depends Entirely on the Cause
There is no single treatment for “spleen pain” because the approach hinges on what is driving it. Mono-related spleen enlargement is managed with rest and activity restrictions until the swelling resolves. A splenic abscess usually requires antibiotics and sometimes drainage. Infarctions are treated by addressing the underlying clotting disorder or heart condition.
For traumatic injuries, the approach has shifted substantially over the past few decades. The current consensus is that any splenic trauma in a patient who is hemodynamically stable should initially be managed without surgery, as long as the hospital has the resources to monitor closely and the patient does not have other injuries requiring abdominal exploration.19PubMed Central. Non-operative management of blunt splenic trauma: evolution, results and controversies Even high-grade injuries can be treated this way. One study found that nonoperative management was as effective as immediate splenectomy in stable adult patients with the most severe grades of blunt splenic injury, and the delay in operating when nonoperative management eventually failed did not worsen outcomes.20PubMed. Nonoperative Management Is as Effective as Immediate Splenectomy for Adult Patients with High-Grade Blunt Splenic Injury
When surgery is unavoidable, surgeons now try to repair the spleen rather than remove it entirely whenever possible. A large study comparing splenic repair to full removal in severe traumatic injuries found that mortality was about half as high in the repair group, roughly 6.5 percent versus nearly 13 percent, and the advantage held up across multiple statistical analyses.21JAMA Network Open. Surgical Repair vs Splenectomy in Patients With Severe Traumatic Spleen Injuries Keeping even part of the spleen matters because of what happens when you lose it entirely.
Warning Signs That Need Immediate Attention
Some spleen-related situations are true emergencies. You should seek care right away if you experience:
- Sudden, severe pain: Sharp, intense pain in the left upper abdomen that comes on quickly, especially after trauma or during an illness known to enlarge the spleen.
- Shoulder pain with abdominal pain: Left shoulder pain combined with left-sided abdominal tenderness can signal blood irritating the diaphragm.
- Lightheadedness or fainting: Feeling dizzy, confused, or on the verge of passing out alongside abdominal pain suggests internal bleeding.
- Rapid heartbeat with dropping blood pressure: These are signs of shock, which can follow splenic rupture as blood pools in the abdomen.
- Fever with left-side pain: The combination raises the possibility of an abscess or infected infarction.
Splenic rupture in particular can deteriorate fast. The case of the 56-year-old man described earlier illustrates how two “warning” episodes of milder pain preceded a sudden collapse. Those earlier twinges may have been small bleeds that temporarily sealed off before the final rupture. Any new or worsening left upper quadrant pain in someone with known splenomegaly warrants prompt evaluation.
Life After Losing Your Spleen
If the spleen does need to come out, the most significant long-term risk is infection. Overwhelming post-splenectomy infection, or OPSI, is uncommon on any given year, estimated at about 0.2 to 0.4 percent per year, but carries a lifetime risk of around 5 percent. When it does occur, it progresses rapidly and is fatal in 38 to 69 percent of cases. The bacterium most commonly responsible is Streptococcus pneumoniae, which accounts for 50 to 90 percent of blood culture isolates in reported OPSI cases.22PubMed. Prevention and management of infections in patients without a spleen
Prevention strategies include vaccination against pneumococcus, meningococcus, and influenza, along with prophylactic antibiotics in certain patients, particularly children.23PubMed. Prevention and treatment of infection in patients with an absent or hypofunctional spleen: A British Society for Haematology guideline Many people who have had a splenectomy carry standby antibiotics to take at the first sign of fever before they can reach a hospital, and some wear a medical alert bracelet. The goal is to start treatment within hours, because OPSI can go from a mild fever to septic shock with alarming speed.
Splenosis and Other Odd Aftereffects
An unusual phenomenon that can cause confusion years after a splenectomy is splenosis, where fragments of splenic tissue seed themselves in other parts of the abdomen and grow into small nodules. These bits of tissue function partly like a miniature spleen, but they can also cause abdominal pain and look worryingly like tumors on imaging. In one documented case, splenic tissue attached to the wall of the large intestine mimicked a gastrointestinal stromal tumor, and the true diagnosis was only confirmed after surgery.24PubMed Central. Cecal splenosis mimicking gastrointestinal stroma tumor. Case report and review of the literature If you have had a splenectomy or a serious splenic injury and develop unexplained abdominal pain or a mysterious mass on a scan years later, splenosis is worth considering before assuming something worse.