Diagnostic Approach and Management of Vomiting and Left Clavicular Pain

Immediate Concerns and Diagnostic Steps

The combination of vomiting and left clavicular pain requires urgent evaluation for cardiac ischemia, esophageal perforation, and aortic dissection, according to the European Society of Cardiology 1.
Cardiac ischemia is a critical concern, as nausea and vomiting frequently accompany acute coronary syndrome, and left clavicular pain can represent radiation of cardiac ischemia, which commonly extends to the left arm, neck, and back, as noted by the European Heart Journal 1.
Women with acute myocardial infarction more frequently experience pain in the neck and jaw, along with nausea and vomiting, highlighting the need for careful evaluation, as recommended by the European Heart Journal 1.
The American Gastroenterological Association suggests that cyclic vomiting syndrome should be considered 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, are present 2.
The National Comprehensive Cancer Network recommends evaluating for gastric outlet obstruction, especially if the patient has known gastric cancer or malignancy, and suggests endoscopic or fluoroscopic evaluation to determine if luminal obstruction is present 3, 4.

The European Society of Cardiology recommends performing an 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, as noted by the European Heart Journal 1.
The National Comprehensive Cancer Network suggests that endoscopic placement of self-expanding metal stents is safe, effective, and minimally invasive for luminal obstruction from advanced gastric cancer 3, 4.
The American Gastroenterological Association recommends abortive therapy during the prodromal phase for cyclic vomiting syndrome, and patient education on recognizing prodromal symptoms is imperative 2.
The European Society of Cardiology advises against dismissing vomiting with left-sided pain as simple gastroenteritis without ECG and cardiac evaluation 1.
The National Comprehensive Cancer Network recommends against delaying endoscopic evaluation if gastric outlet obstruction is suspected, as this guides appropriate palliative management 3, 4.