Pain felt beneath the ribs, encompassing the upper abdomen (epigastric area) and the sides (flanks), can originate from many body systems. This subcostal region houses parts of the digestive system, liver, gallbladder, spleen, lungs, and kidneys. Discomfort can stem from internal organ issues, inflammation of cartilage and muscles, or irritation of the lung lining. Understanding the pain’s characteristics, such as location and timing, offers clues about the underlying cause. Persistent or severe pain, especially with fever, vomiting, or shortness of breath, requires immediate medical evaluation.
Digestive Tract Causes
The upper digestive tract frequently causes discomfort below the rib cage, often presenting as a burning sensation or a dull ache. Gastritis, inflammation of the stomach lining, is a common cause, often resulting from medications, infection, or alcohol use. Gastritis pain typically manifests in the upper middle abdomen and may include bloating or early fullness after eating.
A peptic ulcer, an open sore on the stomach or duodenal lining, causes more localized and intense pain. Duodenal ulcer pain often improves after eating, as food buffers stomach acid, while stomach ulcer pain may intensify shortly after a meal. This deep, gnawing discomfort results from stomach acid eroding the mucosal lining.
Gastroesophageal Reflux Disease (GERD) causes symptoms felt in this area, though it originates in the esophagus. While the characteristic symptom is heartburn, acid reflux can also present as upper abdominal discomfort below the sternum. The pain is often worse when lying down or bending over, allowing stomach contents to flow back up.
Accessory Organ Issues
The liver, gallbladder, pancreas, and spleen are situated beneath the ribs and can cause significant pain. The right upper quadrant (RUQ) houses the liver and gallbladder. Gallbladder issues, such as gallstones blocking bile ducts, cause intense pain called biliary colic, often occurring after consuming a fatty meal.
Prolonged blockage can lead to acute cholecystitis (gallbladder inflammation), presenting as sustained RUQ pain that may radiate to the right shoulder blade or back. Liver conditions like hepatitis or cirrhosis can cause RUQ discomfort if the organ swells. This results in a dull, persistent ache, sometimes accompanied by jaundice (yellowing of the skin and eyes).
Pain in the left upper quadrant (LUQ) may indicate issues with the spleen or pancreas. Pancreatitis (pancreas inflammation) causes severe, steady pain in the upper abdomen that often radiates to the back. This discomfort is worsened by eating and may include nausea and vomiting.
Disorders affecting the spleen, located on the left side, also cause LUQ pain. An enlarged spleen (splenomegaly) results from infections or blood disorders, causing fullness or discomfort under the left rib cage. A splenic rupture, often due to trauma, causes sudden, sharp LUQ pain and requires emergency medical attention due to internal bleeding.
Musculoskeletal and Skeletal Pain
Pain originating from the rib cage, surrounding muscles, or connecting cartilage is a distinct cause of subcostal discomfort. Costochondritis is inflammation of the cartilage joining the ribs to the breastbone (sternum). This typically causes sharp, localized pain that can be reproduced by pressing on the affected joints.
Musculoskeletal pain often worsens with specific movements or actions. A muscle strain of the intercostal muscles (between the ribs) can result from forceful coughing, twisting, or unaccustomed activity. The discomfort is usually a sharp, stabbing sensation that intensifies with deep breaths, sneezing, or changes in posture.
Bruising or fractures of the ribs, often sustained from trauma, also cause pain below the rib cage. Even a hairline fracture can cause significant, localized tenderness. Pain from skeletal injury is generally constant and accompanied by tenderness when the area is touched, distinguishing it from internal sources.
Renal and Respiratory System Involvement
The kidneys and respiratory system are positioned close enough to the rib cage to cause subcostal pain. Kidney issues, such as kidney stones or pyelonephritis (kidney infection), cause pain that often begins in the flank or back and radiates forward below the ribs.
Renal colic, caused by a kidney stone passing through the ureter, is intense, fluctuating, and often accompanied by blood in the urine or painful urination. Pyelonephritis causes a dull, aching pain in the flank region, sometimes felt under the lower ribs. This infection is typically accompanied by systemic symptoms like high fever, chills, and malaise. The pain location depends on which kidney is affected, presenting on the right or left side.
Conditions affecting the lungs and the diaphragm (the muscle beneath the lungs) can also manifest as subcostal pain. Pleurisy, inflammation of the pleura (the membrane lining the lungs), causes a sharp, stabbing pain that worsens dramatically upon deep breathing or coughing. Irritation of the diaphragm or the lower lung portion can cause this pain to be perceived high up in the abdomen, directly beneath the ribs. Pneumonia, a lung infection, can cause similar localized pain when concentrated near the pleural lining, often alongside a cough, fever, and shortness of breath.