Build your differential diagnosis:
Which of these feature in the top 5 of your differential diagnosis?
Peptic Ulcer Disease
Good choice! Given the history of AUD this patient is at risk for PUD. Common causes in addition to alcohol include NSAID use and H. Pylori. Sometimes, patients will complain of epigastric pain related to food (gastric ulcers would be worse with food consumption, while duodenal are typically better with food consumption).
Should be lower on the differential. Although patient may have esophagitis given history of AUD, it is rarely a cause of massive hematemesis. Try again!
Should be lower on the differential. While he is at risk for gastritis, it is less likely to cause massive hematemesis. Try again!
Portal Hypertensive Gastropathy
Should be lower on the differential. While he is at risk for PHG given his history of cirrhosis, this is less likely to cause massive hematemesis. Try again!
Good choice. A dieulafoy lesion can bleed and present with hematemesis. Those who bleed often have comorbidities such as cardiovascular disease, hypertension, chronic kidney disease and AUD. NSAID use has also been reported as a risk factor for bleeding.
Good choice. Given the history of AUD and preceding vomiting, this patient is at risk for Mallory-Weiss Tear. Typically patients will experience excessive retching preceding hematemesis.
Esophageal Variceal Bleed
Good choice. Given the history of AUD and cirrhosis, this patient is at high risk for esophageal variceal bleed. ~50% of patients with cirrhosis have esophageal varices, 1/3 of whom will develop hemorrhage.
Mass Lesions (polyps/cancer)
Should be lower on the differential, while esophageal, gastric and duodenal tumors can bleed, they rarely cause acute bleeding and account for only ~3.0% of UGIB. Try again!
Gastric Variceal Bleed
Good choice. Although they bleed less frequently than esophageal varices, gastric varices account for 10-30% of variceal hemorrhages, bleed more severely and carry higher mortality.
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