What is the best course of action for a patient with acute left upper quadrant (LUQ) abdominal pain and leukocytosis (elevated White Blood Cell (WBC) count) shortly after initiating Ozempic (semaglutide) therapy?

Acute LUQ Pain with Leukocytosis After Starting Ozempic

Immediate Action Required

This patient requires urgent CT abdomen/pelvis with IV contrast to rule out acute appendicitis and other surgical emergencies, despite the atypical left upper quadrant location. 1, 2

Critical Diagnostic Considerations

Primary Concern: Atypical Appendicitis

• Acute appendicitis can present with left upper quadrant pain in patients with intestinal malrotation or other anatomic variants, making this a potentially life-threatening presentation that requires immediate imaging. 3
• The combination of acute abdominal pain, focal tenderness, and WBC of 20.5 represents significant leukocytosis that mandates exclusion of surgical pathology—this degree of elevation is highly concerning for an acute intra-abdominal process. 1
• CT abdomen/pelvis with IV contrast achieves 85.7-100% sensitivity and 94.8-100% specificity for appendicitis and will identify alternative diagnoses in 23-45% of cases with acute abdominal pain. 4, 1

GLP-1 Receptor Agonist Consideration

• Recent initiation of Ozempic (semaglutide) may increase risk of appendicitis, though the mechanism remains unclear—case reports document appendicitis developing within months of GLP-1 RA initiation, potentially related to gastrointestinal motility effects and increased intraluminal pressure. 5
• However, the temporal association with Ozempic does not change the immediate management priority: ruling out surgical emergencies first. 5

Diagnostic Algorithm

Immediate Laboratory Workup

• Obtain complete blood count with differential to assess neutrophil predominance (already showing WBC 20.5). 1
• Measure C-reactive protein—CRP ≥5 mg/dL has high specificity for intra-abdominal pathology. 1
• Check serum lactate if concerned about bowel ischemia or sepsis, given the significant leukocytosis. 1
• Obtain 2 sets of blood cultures before any antibiotics if fever is present or patient appears septic. 6, 1

Imaging Strategy

• Order CT abdomen/pelvis with IV contrast immediately—this is the definitive study with superior sensitivity and specificity for identifying surgical causes of acute abdominal pain with leukocytosis. 1, 2
• Plain radiographs have no role here, with only 25% sensitivity and should only be used if CT is unavailable. 1
• Ultrasound alone is insufficient in this setting—while positive predictive value is comparable to CT, negative or inconclusive ultrasound must be followed by CT. 2

Specific Imaging Considerations for LUQ Pain

• Radiologist must be alerted to evaluate for intestinal malrotation and ectopic appendix location, as left-sided appendicitis, though rare, can occur with congenital malrotation and polysplenia. 3
• CT will also identify alternative LUQ pathologies including splenic pathology, left colonic diverticulitis, renal pathology, and pancreatic processes. 7, 2

Management Based on Imaging Results

If Appendicitis Confirmed (Even in LUQ)

• Immediate surgical consultation is mandatory regardless of appendix location—atypical presentations may result in diagnostic and management delay, increasing morbidity and mortality. 3
• Start empiric broad-spectrum antibiotics immediately after obtaining blood cultures: Cefotaxime 2g IV every 8 hours plus Metronidazole 500mg IV every 8 hours. 1
• Laparoscopic approach may require conversion to open if malrotation is present. 3

If Diverticulitis Identified

• Left-sided colonic diverticulitis can present with LUQ pain and significant leukocytosis. 7
• For uncomplicated diverticulitis without significant comorbidities or sepsis, antibiotics may be avoided with close clinical monitoring. 7
• For complicated diverticulitis with abscess <4cm, treat with IV antibiotics alone; abscesses >4cm require percutaneous drainage plus antibiotics. 7

If Imaging is Negative or Shows Alternative Diagnosis

• Consider inflammatory bowel disease complications (abscess, fistula, stricture) given the significant leukocytosis—IBD patients can present with acute abdominal pain and elevated inflammatory markers. 7
• Evaluate for mesenteric ischemia if patient has cardiac disease or atrial fibrillation, though this typically presents with pain out of proportion to exam. 7
• If no acute pathology identified but symptoms persist, mandatory 24-hour follow-up with repeat examination and consideration of repeat imaging. 4

Critical Pitfalls to Avoid

• Do not dismiss LUQ pain as "atypical" for appendicitis without imaging—intestinal malrotation occurs in 1:500 live births and may remain asymptomatic until acute complications develop. 3
• Do not attribute symptoms solely to GLP-1 RA side effects without excluding surgical emergencies—while nausea and vomiting are common with Ozempic, acute pain with WBC 20.5 demands investigation. 5
• Do not start empiric antibiotics before obtaining blood cultures if there is any concern for sepsis or intra-abdominal infection. 6, 1
• Do not rely on absence of fever to exclude serious pathology—fever is absent in approximately 50% of appendicitis cases. 4
• Do not delay imaging if patient has peritoneal signs (guarding, rigidity, rebound tenderness)—these findings warrant immediate CT regardless of location of pain. 4, 1

Monitoring During Workup

• Serial abdominal examinations every 4-6 hours to assess for progression of peritoneal signs while awaiting imaging. 4
• Maintain NPO status and ensure adequate IV hydration. 4
• Provide appropriate analgesia—opioids do not mask physical examination findings and should not be withheld. 2
• If patient develops hemodynamic instability, altered mental status, or worsening peritoneal signs, expedite imaging and surgical consultation immediately. 1