What is the diagnosis and management for a patient with persistent upper left abdominal pain and nausea/vomiting (n/v) for 5 days, unrelieved by Tums (calcium carbonate), with tenderness to palpation, and no history of trauma?

Differential Diagnosis and Urgent Evaluation

This patient requires immediate CT abdomen/pelvis with IV contrast to identify the cause of persistent upper left abdominal pain with nausea/vomiting unrelieved by antacids, as this presentation could represent serious pathology including splenic pathology, pancreatitis, gastric perforation, or left-sided colonic diverticulitis. 1

Initial Assessment and Red Flag Identification

• Check vital signs immediately for tachycardia, hypotension, fever, and tachypnea—these combinations predict serious complications including perforation, bowel ischemia, or sepsis 1
• Assess for peritoneal signs including rebound tenderness, guarding, or rigidity, which indicate possible perforation or bowel necrosis 1
• Evaluate for hemodynamic instability—signs of shock mandate immediate surgical exploration without delay 1

The 5-day duration of symptoms with tenderness to palpation and failure to respond to antacids is concerning and warrants aggressive investigation rather than empirical treatment. 2

Critical Laboratory Testing

Obtain the following labs immediately: 1, 3

• Complete blood count, electrolytes, renal function
• Blood gas and lactate levels (essential for detecting bowel ischemia—elevated lactate is a critical warning sign) 1
• Liver function tests (AST, ALT, ALP, GGT, bilirubin, albumin) 4, 3
• Lipase (to evaluate for pancreatitis) 3
• C-reactive protein (elevated CRP >140 mg/L predicts progression to complicated disease) 4
• Urinalysis (to exclude renal/urologic causes) 3

Critical caveat: Absence of peritonitis does NOT exclude bowel ischemia—lactate and blood gas are essential. 1

Imaging Strategy

CT abdomen/pelvis with IV contrast is the definitive first-line test and should be obtained urgently to: 4, 1

• Confirm or exclude acute pathology (splenic cyst, abscess, or infarction)
• Identify bowel obstruction and transition points
• Detect bowel ischemia
• Rule out pancreatitis, perforated viscus, or abscess formation
• Evaluate for left-sided colonic diverticulitis

Plain abdominal radiographs have limited sensitivity and negative films do NOT exclude serious pathology—proceed directly to CT if clinical suspicion is high. 1

Differential Diagnosis by Location

Upper left quadrant pain with nausea/vomiting suggests: 5, 6, 7

• Splenic pathology (cyst, abscess, infarction)—splenic cysts can present with upper abdominal pain, nausea, and vomiting with left upper quadrant tenderness 5
• Pancreatitis—typically presents with severe epigastric/left upper quadrant pain radiating to back with nausea/vomiting 2
• Gastric pathology (perforation, gastric outlet obstruction)—Boerhaave's syndrome (esophageal rupture) presents with sudden upper abdominal pain after excessive vomiting 6
• Left-sided colonic diverticulitis—presents with left lower quadrant pain but can have upper abdominal symptoms 4
• Sigmoid volvulus—triad of abdominal pain, constipation, and vomiting 1

Immediate Management While Awaiting Imaging

Initiate supportive care immediately: 1, 3

• NPO status (nothing by mouth)
• IV fluid resuscitation with aggressive crystalloid administration for dehydration from vomiting 1
• Nasogastric tube decompression if bilious vomiting or suspected obstruction 1
• Antiemetic therapy with metoclopramide 10 mg IV every 6 hours or ondansetron 4-8 mg IV (but NOT if mechanical obstruction is suspected) 3, 8

Critical pitfall: Never use antiemetics in suspected mechanical bowel obstruction, as this can mask progressive ileus and gastric distension. 3, 8

Risk Stratification for Complicated Disease

Predictors of progression to complicated disease include: 4

• Symptoms lasting longer than 5 days (this patient meets this criterion)
• Persistent vomiting
• High C-reactive protein levels (>140 mg/L)
• CT findings of pericolic extraluminal air, fluid collection, or longer inflamed colon segment

Specific Diagnostic Considerations

If Splenic Cyst is Identified

• Splenic cysts are rare and can present with upper abdominal pain, nausea, and vomiting with left upper quadrant tenderness 5
• Echinococcus serology should be tested to exclude parasitic etiology 5
• Surgical consultation for potential laparoscopic fenestration or splenectomy 5

If Diverticulitis is Identified

• Uncomplicated diverticulitis (localized inflammation without abscess, perforation, or obstruction) in select immunocompetent patients can be managed outpatient without antibiotics if no systemic inflammatory response 4
• Complicated diverticulitis (abscess, perforation, obstruction) requires hospitalization, antibiotics, and possible surgical intervention 4

If Pancreatitis is Identified

• Lipase elevation confirms diagnosis 3
• Supportive care with IV fluids, NPO status, and pain control 2
• Identify and treat underlying cause (gallstones, alcohol, medications) 2

When to Obtain Surgical Consultation

Obtain immediate surgical consultation if: 1

• Signs of peritonitis (rebound, guarding, rigidity)
• Hemodynamic instability or signs of shock
• Suspected bowel obstruction, perforation, or ischemia
• Large splenic cyst or abscess requiring intervention
• Complicated diverticulitis with abscess or perforation

Antiemetic Strategy if Obstruction is Excluded

If mechanical obstruction is ruled out and vomiting persists: 3, 8

• First-line: Metoclopramide 10-20 mg IV/PO every 6 hours (scheduled, not PRN) 8
• Alternative: Prochlorperazine 10 mg IV/PO every 6 hours or 25 mg suppository PR every 12 hours 8
• Add ondansetron 8 mg IV if symptoms persist after initial dopamine antagonist 8
• Consider dexamethasone 12 mg IV for complementary antiemetic coverage 8

Monitor for extrapyramidal symptoms with metoclopramide/prochlorperazine, particularly in young males—treat immediately with diphenhydramine 50 mg IV if they occur. 8

Reassessment Timeline

• Reassess within 24-48 hours of initiating treatment 8
• If no improvement within 48 hours, escalate diagnostic workup rather than further medication adjustments 8
• Serial abdominal exams every 4-6 hours to detect development of peritonitis 1