What are the potential causes and management of vomiting and left clavicular pain?

Vomiting and Left Clavicular Pain: Diagnostic Approach and Management

Immediate Concern: Rule Out Life-Threatening Causes

The combination of vomiting and left clavicular pain requires urgent evaluation for cardiac ischemia, esophageal perforation (Boerhaave's syndrome), and aortic dissection before considering other diagnoses. 1

Critical Red Flags to Assess

• Cardiac ischemia: Nausea and vomiting frequently accompany acute coronary syndrome and point to a cardiac cause of chest pain 1. Left clavicular pain can represent radiation of cardiac ischemia, which commonly extends to the left arm, neck, and back 1. Women with acute myocardial infarction more frequently experience pain in the neck and jaw, along with nausea and vomiting 1.

• Boerhaave's syndrome: Acute upper abdominal or chest pain after excessive vomiting suggests spontaneous esophageal rupture, which has high mortality if left untreated 2. This presents as sudden-onset pain following vomiting episodes 2.

• Aortic dissection: Severe pain with associated autonomic symptoms (pallor, diaphoresis, nausea, vomiting) should raise concern for dissection 1.

Diagnostic Algorithm

Step 1: Obtain 12-Lead ECG Immediately

• Perform ECG to identify ST-segment changes indicating myocardial ischemia, though sensitivity is only 50% for detecting ischemia 1.
• ST-depressions indicate myocardial ischemia and warrant immediate cardiac evaluation 1.

Step 2: Characterize the Vomiting Pattern

Acute vomiting (≤7 days): 3, 4

• Consider gastroenteritis, foodborne illness, medication adverse effects, early pregnancy, vestibular disturbances, or acute migraine 4.
• Boerhaave's syndrome if pain developed suddenly after excessive vomiting 2.

Chronic vomiting (≥4 weeks): 3, 4

• Consider cyclic vomiting syndrome if stereotypical episodes of acute-onset vomiting lasting <7 days, with at least 3 discrete episodes per year separated by at least 1 week of baseline health 1.
• Evaluate for gastric outlet obstruction, especially if patient has known gastric cancer or malignancy 1.

Step 3: Assess Left Clavicular Pain Characteristics

Musculoskeletal causes:

• Stress fractures of the clavicle occur in athletes (divers, gymnasts) with repetitive upper extremity loading 5, 6.
• Physeal stress lesions at the proximal clavicular growth plate present with insidious onset pain in adolescent athletes 6.
• Pain typically worsens with activity and improves with rest 5, 6.

Referred pain patterns:

• Cardiac ischemia radiating to left shoulder/clavicular region 1.
• Diaphragmatic irritation from subphrenic pathology (splenic injury, abscess) can refer to left shoulder via phrenic nerve (Kehr's sign).

Step 4: Order Appropriate Imaging

If cardiac or esophageal perforation suspected:

• CT chest/abdomen/pelvis with IV contrast is the gold standard 1, 2.
• CT identifies extraluminal air from perforation, mediastinal changes, and cardiac complications 2.

If musculoskeletal clavicular pathology suspected:

• Plain radiographs initially, though may be normal in early stress fractures 5, 6.
• CT scan or radionuclide bone scan confirms stress fractures 5, 6.

If gastric outlet obstruction suspected:

• Endoscopic or fluoroscopic evaluation to determine if luminal obstruction is present 1.

Management Based on Etiology

For Nausea/Vomiting Symptom Control

First-line antiemetics: 1, 4

• Metoclopramide 10-20 mg orally three to four times daily (dopamine antagonist) 7.
• Prochlorperazine 10 mg orally every 6 hours 8.

Second-line for persistent symptoms: 1, 7

• Add 5-HT3 receptor antagonist: ondansetron 4-8 mg two to three times daily 7.
• Combination therapy with metoclopramide plus ondansetron provides synergistic relief 8.

For cyclic vomiting syndrome: 1

• Abortive therapy during prodromal phase is critical—earlier intervention increases probability of aborting an episode 1.
• Patient education on recognizing prodromal symptoms (impending doom, panic, constitutional symptoms) is imperative 1.

For Gastric Outlet Obstruction

• Endoscopic placement of self-expanding metal stents is safe, effective, and minimally invasive for luminal obstruction from advanced gastric cancer 1.
• Gastrojejunostomy is preferable in patients with prolonged prognosis, while stent placement favors those with shorter life expectancy 1.
• If endoscopic restoration fails, percutaneous endoscopic gastrostomy for gastric decompression may be performed if tumor location permits 1.

For Boerhaave's Syndrome

• Surgical intervention is indicated if patient is hemodynamically unstable, has sepsis, or diagnosis is made within 24 hours 2.
• Otherwise, minimally invasive approach with antibiotics, pleural drainage, and endoscopic stent placement should be considered 2.

For Clavicular Stress Fractures

• Active rest with avoidance of provocative activities allows complete fracture healing 5, 6.
• Healing typically occurs over weeks to months with conservative management 5, 6.

Critical Pitfalls to Avoid

• Do not dismiss vomiting with left-sided pain as simple gastroenteritis without ECG and cardiac evaluation 1.
• Do not ignore severe pain after vomiting episodes—this is Boerhaave's syndrome until proven otherwise 2.
• Do not assume normal radiographs exclude stress fractures in athletes with clavicular pain—advanced imaging may be necessary 5, 6.
• Do not use metoclopramide chronically without monitoring for extrapyramidal side effects and tardive dyskinesia, particularly in elderly patients 7.
• Do not delay endoscopic evaluation if gastric outlet obstruction is suspected, as this guides appropriate palliative management 1.