From the Guidelines
The workup for a patient with left upper abdominal pain and vomiting for 5 days should begin with a thorough history and physical examination, followed by laboratory tests including complete blood count, comprehensive metabolic panel, lipase, and amylase, as the initial step in narrowing down the differential diagnosis, which includes a broad range of pathologies such as pneumonia, hepatobiliary disease, complicated pancreatic processes, nephrolithiasis, gastrointestinal (GI) perforation or inflammation, bowel obstruction or infarction, abscesses, and tumor 1.
When considering the management of a patient with left upper abdominal pain and vomiting, it's crucial to prioritize the most likely causes based on the presentation. The symptoms of left upper abdominal pain and vomiting could be indicative of several conditions, including pancreatitis, gastritis, splenic disorders, left-sided nephrolithiasis, and bowel obstruction.
- Initial laboratory tests should include:
- Complete blood count (CBC) to assess for signs of infection or inflammation
- Comprehensive metabolic panel (CMP) to evaluate electrolyte balance and renal function
- Lipase and amylase to assess for pancreatitis
- Initial imaging should include:
- Abdominal X-ray to evaluate for bowel obstruction or free air under the diaphragm
- Ultrasound to assess the gallbladder, liver, spleen, and kidneys
- Consideration for CT scan with contrast if the diagnosis remains unclear, as it can provide detailed images of the abdominal organs and help identify conditions such as pancreatitis, abscesses, or tumors 1
Management should start with fluid resuscitation using isotonic crystalloids, such as normal saline or lactated Ringer's at 1-2 L bolus followed by maintenance, to correct dehydration and maintain perfusion of vital organs.
- Antiemetics such as ondansetron 4-8 mg IV/PO every 8 hours or promethazine 12.5-25 mg IV/IM/PO every 4-6 hours should be used to control vomiting.
- Pain control with acetaminophen 1000 mg every 6 hours or, if needed, opioids like morphine 2-4 mg IV every 4 hours should be considered.
- NPO (nothing by mouth) status is typically recommended initially, with gradual diet advancement as tolerated.
The differential diagnosis for left upper abdominal pain includes:
- Pancreatitis
- Gastritis
- Splenic disorders
- Left-sided nephrolithiasis
- Bowel obstruction
Specific management will be directed by the identified cause. For example:
- Acute pancreatitis would require aggressive fluid resuscitation.
- Gastritis might need proton pump inhibitors such as pantoprazole 40 mg IV/PO daily.
Persistent symptoms despite initial management or signs of peritonitis, severe dehydration, or hemodynamic instability warrant urgent surgical consultation and possible hospital admission. Imaging, particularly CT scans, plays an essential role in determining management, especially in instances where the positive result is not concordant with the initial diagnostic consideration 1.
From the Research
Workup for Left Upper Abdominal Pain and Vomiting
The workup for a patient with left upper abdominal pain and vomiting for 5 days involves a combination of clinical evaluation, laboratory tests, and imaging studies.
- Clinical evaluation is advised to differentiate between urgent and nonurgent causes 2.
- The diagnostic accuracy of clinical assessment is insufficient to identify the correct diagnosis but can discriminate between urgent and nonurgent causes 2.
- Patients suspected of nonurgent diagnoses can safely be reevaluated the next day 2.
Differential Diagnoses
The differential diagnoses for left upper abdominal pain and vomiting include:
- Boerhaave's syndrome, a spontaneous oesophageal rupture caused by excessive vomiting 3.
- Small bowel obstruction, cyclic vomiting, and gastroparesis 4.
- Acute pancreatitis, which can be caused by various factors, including drug-induced pancreatitis 5.
- Other causes of acute abdominal pain, such as gallstones, biliary ductal dilatation, or choledocholithiasis 2.
Diagnostic Imaging
- Computed tomography (CT) leads to the highest sensitivity and specificity in patients with acute abdominal pain 2.
- Ultrasound is preferred as the first imaging modality due to the downsides of computed tomography, and negative or inconclusive ultrasound is followed by CT 2.
- Conventional radiography has no place in the work-up of patients with acute abdominal pain due to the lack of added value on top of clinical assessment 2.
Management
- Management of small bowel obstruction involves correction of physiologic and electrolyte disturbances, bowel rest, and removing the source of the obstruction 4.
- Treatment of acute cyclic vomiting is primarily directed at symptom control, volume and electrolyte repletion, and appropriate specialist follow-up 4.
- The mainstay of therapy for gastroparesis is metoclopramide 4.
- Antibiotic treatment should be started within the first hour after recognition of sepsis 2.
- Administration of opioids (analgesics) decreases the intensity of the pain and does not affect the accuracy of physical examination 2.