Rib Cage Pain: Differential Diagnosis and When to Seek Care

Pain under the rib cage arises from thoracic, abdominal, or referred sources. A systematic approach narrows the differential.

Common Causes by Region

Region	Conditions	Key Features
Right Upper Quadrant	Cholecystitis, choledocholithiasis, hepatitis, liver capsule stretch	Postprandial, Murphy's sign, fever, jaundice
Left Upper Quadrant	Splenomegaly, gastritis, pancreatitis (referred), splenic infarct	Early satiety, LUQ tenderness, labs
Chest Wall	Costochondritis, rib fracture, intercostal neuralgia, herpes zoster	Reproducible tenderness, trauma history, dermatomal rash
Pulmonary	Pleuritis, pneumonia, PE, pneumothorax	Pleuritic pain, dyspnea, cough, hypoxia
Cardiac	Angina, MI, pericarditis	Exertional, pressure, radiation, ECG/trop changes
GI	GERD, hiatal hernia, peptic ulcer, esophageal spasm	Meal-related, positional, acid brash
Renal	Nephrolithiasis, pyelonephritis	Colicky flank→groin, hematuria, fever

Red Flags for Immediate Evaluation

• Crushing chest pain, radiation, diaphoresis, syncope.
• Sudden severe tearing back/chest pain (aortic dissection).
• Hemoptysis, high fever with rigors.
• Inability to find comfortable position (peritonitis).

Diagnostic Approach

History (onset, quality, radiation, triggers) → focused exam → ECG, troponin, CXR, basic labs → targeted imaging (US abdomen, CT chest/abdomen, endoscopy) based on suspicion.