Mr. M is a 39-year-old man who arrives at the emergency department after vomiting blood. He reports waking the morning of admission with an “upset stomach.” He initially attributed this to a hangover. After about an hour he vomited “a gallon of blood” with no other stomach contents. Almost immediately afterward, he had a second episode of hematemesis and called 911.
At this point, what is the leading hypothesis, what are the active alternatives, and is there a must not miss diagnosis? Given this differential diagnosis, what tests should be ordered?
RANKING THE DIFFERENTIAL DIAGNOSIS
Mr. M is having an upper GI bleed. The hematemesis is a pivotal point in this case and localizes the source of the bleeding to above the ligament of Treitz. Peptic ulcer disease and gastritis are the most common causes of upper GI bleeding. Although not always present, preceding symptoms of abdominal distress are common with peptic ulcer disease and gastritis. When incorporating patient-specific risk factors, such as this patient’s alcohol use, esophageal varices should be added to the differential diagnosis. The details of the patient’s alcohol use are still unknown, so his risk of portal hypertension cannot be predicted. A Mallory-Weiss tear is also possible, but the patient would report vomiting before the onset of bleeding. Table 19-4 lists the differential diagnosis.
Table 19-4.Diagnostic hypotheses for Mr. M. ||Download (.pdf) Table 19-4. Diagnostic hypotheses for Mr. M.
|Diagnostic Hypotheses ||Demographics, Risk Factors, Symptoms and Signs ||Important Tests |
|Leading Hypothesis |
|Peptic ulcer disease || |
Relation of pain to eating
Tests for Helicobacter pylori
|Active Alternative |
|Gastritis ||Often asymptomatic prior to hemorrhage ||EGD |
|Active Alternative—Must Not Miss |
|Esophageal varices || |
History of portal hypertension, usually due to cirrhosis
Stigmata of chronic liver disease
Liver biochemical tests
|Other Alternative |
|Mallory-Weiss tear ||Hematemesis preceded by vomiting, especially with retching ||EGD |
On further history, the patient reports no previous episodes of GI bleeding. He reports occasional stomach upset, usually following drinking binges. He denies NSAID use. Mr. M says that he has been drinking heavily since his late teens. He drinks at least a fifth of hard liquor and a 6-pack of beer daily for the last 20 years. He reports that he has not seen a doctor since his pediatrician.
On physical exam, Mr. M is anxious and appears tired. He smells of alcohol. While sitting, his BP is 140/80 mm Hg and his pulse is 100 bpm. While standing, his BP is 100/80 mm Hg and his pulse is 130 bpm. His temperature is 37.0°C and RR is 16 breaths per minute. Sclera are slightly icteric. Lungs are clear and heart is tachycardic but regular. Abdomen is soft without hepatomegaly. There is no ascites, but the spleen is palpable about 2 cm below the costal margin.