A 52-year-old man comes to the physician due to black stools. He also has occasional abdominal discomfort and nausea but has no hematemesis. Food seems to help his abdominal pain, so he eats frequently during the day and occasionally snacks at night. As a consequence, the patient has gained 5 pounds over the last year. He says his diet is lacking in vegetables and fruit. The patient drinks 1 to 2 cans of beer nightly but does not use tobacco or illicit drugs. His father died of colon cancer, and his mother died from stroke. Physical examination shows mild epigastric abdominal tenderness and a right-sided carotid bruit. Fecal occult blood testing is positive. Which of the following is the most likely diagnosis?

Question

A 52-year-old man comes to the physician due to black stools.  He also has occasional abdominal discomfort and nausea but has no hematemesis.  Food seems to help his abdominal pain, so he eats frequently during the day and occasionally snacks at night.  As a consequence, the patient has gained 5 pounds over the last year.  He says his diet is lacking in vegetables and fruit.  The patient drinks 1 to 2 cans of beer nightly but does not use tobacco or illicit drugs.  His father died of colon cancer, and his mother died from stroke.  Physical examination shows mild epigastric abdominal tenderness and a right-sided carotid bruit.  Fecal occult blood testing is positive.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d274_59c8_bc81_7b3fefa7a949_MD0003_00 This patient's epigastric abdominal discomfort and melena are likely due to peptic ulcer disease (PUD). PUD refers to ulcerations in the stomach or duodenum that are most commonly caused by Helicobacter pylori infection or nonsteroidal anti-inflammatory drugs. Patients may have epigastric pain, nausea, and/or early satiety in association with food. The classic symptoms of duodenal ulcer occur in the absence of a food buffer and can include epigastric pain 2-5 hours after meals, on an empty stomach, or at night. Patients can have melena due to processed blood from upper gastrointestinal (GI) bleeding (eg, proximal to the ligament of Treitz). In fact, PUD is one of the most common causes of upper GI bleeding. Diagnosis of PUD is made with upper GI endoscopy. (Choices A and B) Colon cancer and diverticulosis are possible etiologies of lower GI bleeding that typically present with hematochezia as opposed to melena. Colon cancer may also result in changes in bowel habits (eg, constipation, changes in stool caliber). (Choice C) Gastric cancer can cause melena and abdominal pain but is usually accompanied by weight loss and anorexia instead of weight gain. (Choice D) Ulcerative colitis typically causes hematochezia as opposed to melena. Melena can occur with Crohn disease involving the upper GI tract or small bowel. Nonetheless, inflammatory bowel disease is typically accompanied by diarrhea and systemic symptoms (eg, fatigue, fever, weight loss), which are not evident in this patient. (Choices E and G) Atherosclerotic vascular disease (eg, carotid stenosis) is a risk factor for chronic ischemic colitis and mesenteric ischemia. However, ischemic colitis is typically associated with hematochezia as opposed to melena. In addition, patients with mesenteric ischemia report pain that is exacerbated by eating, which often leads to food aversion and weight loss as opposed to weight gain. (Choice F) Mallory-Weiss syndrome refers to hematemesis that occurs after repeated episodes of retching/vomiting and is often accompanied by epigastric or back pain. The absence of vomiting and hematemesis in this patient make the diagnosis unlikely. Educational objective: Peptic ulcer disease (PUD) may present with epigastric pain, nausea, and/or early satiety in association with food. Symptoms of duodenal ulcer classically occur in the absence of a food buffer (eg, 2-5 hours after meals, on an empty stomach, or at night). Melena is a manifestation of upper gastrointestinal bleeding, with PUD being one of the most common causes. References: Diagnosis and management of upper gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/22534226) Peptic ulcer disease. (http://www.ncbi.nlm.nih.gov/pubmed/17956071)

A 52-Year-Old Man Comes to the Physician Due to Black