A 33-year-old man comes to the emergency department due to abdominal discomfort, nausea, and 2 episodes of vomiting containing a small amount of blood over the past several hours. The symptoms all started this morning. He has no prior medical problems and has never had similar symptoms. The patient drank alcohol and used cocaine with his friends late last night. This morning, he woke up with a "terrible" headache for which he took several aspirin tablets. The headache improved, but he subsequently developed the gastrointestinal symptoms. The patient smokes a pack of cigarettes daily and drinks 1 or 2 cans of beer daily. Vital signs are normal. Abdominal examination reveals mild epigastric tenderness, but no masses, rebound, or guarding. Which of the following is the most likely cause of this patient's hematemesis?

Question

A 33-year-old man comes to the emergency department due to abdominal discomfort, nausea, and 2 episodes of vomiting containing a small amount of blood over the past several hours.  The symptoms all started this morning.  He has no prior medical problems and has never had similar symptoms.  The patient drank alcohol and used cocaine with his friends late last night.  This morning, he woke up with a "terrible" headache for which he took several aspirin tablets.  The headache improved, but he subsequently developed the gastrointestinal symptoms.  The patient smokes a pack of cigarettes daily and drinks 1 or 2 cans of beer daily.  Vital signs are normal.  Abdominal examination reveals mild epigastric tenderness, but no masses, rebound, or guarding.  Which of the following is the most likely cause of this patient's hematemesis?

Quizplus · Accepted Answer

Acute erosive gastropathy is characterized by the development of severe hemorrhagic lesions after the exposure of gastric mucosa to various injurious agents or after a substantial reduction in blood flow. Aspirin decreases the protective prostaglandin production, and cocaine results in vasoconstriction, significantly reducing gastric blood flow. In addition, aspirin and alcohol cause direct mucosal injury, which decreases the normal protective barriers (eg, secreted mucins, bicarbonate), thereby permitting acid and other luminal substances (eg, proteases, bile acids) to penetrate into the lamina propria. This results in additional injury to the vasculature and subsequent hemorrhage. As in this case, patients frequently present with hematemesis and abdominal pain. (Choice A) Aortoenteric fistula can present as massive, life-threatening gastrointestinal (GI) hemorrhage or as minimal bleeding (a common sentinel event of massive hemorrhage). However, this patient lacks typical risk factors for aortoenteric fistula, including older age, history of abdominal aortic aneurysm, prior GI interventions, or malignancy. (Choice B) Esophageal variceal bleeding is another common cause of upper GI bleeding, but it is usually seen in patients with cirrhosis. This patient is young, has a history of moderate alcohol consumption, and has no other findings suggestive of chronic liver disease (eg, ascites, spider angiomata, jaundice). (Choice D) Both Staphylococcus aureus and Bacillus cereus produce heat-stable enterotoxins that can lead to significant vomiting after the consumption of contaminated food. However, this patient describes only minimal vomiting, and neither S aureus nor B cereus food-poisoning commonly leads to hematemesis. (Choice E) Pancreatitis may be caused by alcohol consumption; however, it typically causes severe abdominal pain (classically without hematemesis) and usually occurs after years of heavy alcohol use rather than a single event of binge drinking. Cocaine use is much more commonly associated with mesenteric ischemia than with acute pancreatitis. (Choice F) Mallory-Weiss tears occur in the distal esophagus at the gastroesophageal junction after repeat bouts of retching and vomiting. Patients typically have a history of multiple episodes of nausea and vomiting preceding the onset of hematemesis, not concurrent with its first presentation (as in this patient). Educational objective: Acute erosive gastropathy is characterized by the development of hemorrhagic lesions after ischemia or the exposure of gastric mucosa to various injurious agents (eg, alcohol, aspirin, cocaine). References: Diagnosis of gastrointestinal bleeding: a practical guide for clinicians. (http://www.ncbi.nlm.nih.gov/pubmed/25400991) Alcoholic disease: liver and beyond. (http://www.ncbi.nlm.nih.gov/pubmed/25356028)

A 33-Year-Old Man Comes to the Emergency Department Due to Abdominal