Question

A 33-year-old woman, gravida 2 para 1, at 29 weeks gestation comes to the emergency department due to right-sided abdominal pain. The pain developed yesterday morning, initially resolved with acetaminophen, but has become increasingly severe over the past few hours. The patient now has continuous nausea and has vomited twice. She has not had a bowel movement in 2 days. She has had uterine contractions, but no vaginal bleeding or leakage of fluid. The patient has no chronic medical conditions, and her only surgery was a cesarean delivery for failure to progress. Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, and pulse is 118/min. BMI is 30 kg/m². Fetal heart rate monitoring shows a baseline of 160/min and no decelerations. Tocodynamometry shows regular uterine contractions every 1-2 minutes. The abdomen is tender to palpation, but has no rebound or guarding. The uterus has fundal tenderness and an associated firm, tender mass. On pelvic examination, the cervix is closed. Leukocyte count is 19,000/mm'. Urinalysis is normal. Which of the following is the most likely diagnosis in this patient?

Answer 1

The most likely cause of hematemesis in this patient is Peptic ulcer disease. Option D is correct

Peptic ulcer disease, which can cause hemorrhage, is the most likely diagnosis. Although she did not have some of the normal symptoms, such as nocturnal discomfort, this patient did report epigastric pain with radiation to the back, which was consistent with a duodenal ulcer. Acute epigastric pain with radiation to the back is also a sign of a penetrating duodenal ulcer, which can lead to pancreatitis.

Patients with a Mallory-Weiss tear usually have a history of vomiting or wrenching before the bleeding, making this diagnosis less likely. In adults, eosinophilic esophagitis commonly manifests with intermittent food impaction and dysphagia.1 Our patient had neither, making this an incorrect diagnosis. Gastric adenocarcinoma may manifest with epigastric pain, but the mean age for patients at presentation is 60 years, and this disorder is more common in men.

the missing part of the question is:

What is the most likely cause of hematemesis in this patient?

a

Mallory-Weiss tear

b

Eosinophilic esophagitis

c

Gastric adenocarcinoma

d

Peptic ulcer disease

e

Esophageal varices