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Question 6#

A 30-year-old male smoker presents to the emergency room complaining of chest pain and hematemesis, having vomited up two cups of blood. He admits to drinking too much that same evening and having vomited repeatedly after drinking shots of vodka with his friends following a sporting event. His chest pain is worse after each episode of vomiting; he has never had a cardiac problem in the past. His past history is important for only for hypertension controlled with hydrochlorothiazide. He denies any previous history of alcohol abuse. On examination he is anxious and diaphoretic. His supine pulse is 90, with a blood pressure of 110/90. Heart and lungs are normal, and he has mild epigastric tenderness. His hemoglobin is 11. Stool is hemoccult positive. EKG and initial cardiac enzymes are normal. You admit the patient to the intensive care unit and consult a gastroenterologist.

What is the most likely outcome of this patients gastrointestinal bleeding? 

a. Spontaneous resolution of the acute upper GI bleeding within 24 to 48 hours
b. Recurrent massive upper GI bleeding within a few hours
c. Continued slow bleeding
d. Mental status deterioration within a few hours
e. Development of fever and intense right lower quadrant pain within a few hours

Correct Answer is A

Comment:

This patient has a Mallory-Weiss tear, which is the cause of bleeding in approximately 5% of patients with an acute upper GI bleed. Most of these tears heal spontaneously within 24 to 48 hours with supportive therapy. If there is ongoing bleeding, IV vasopressin or injection of a sclerotic agent via endoscopy may be required. Surgical intervention with oversewing of the bleeder is rarely needed. The history is not suggestive of chronic alcoholism which may be associated with esophageal varices and hence a higher risk of recurrent massive bleeding as well as mental status deterioration. Acute appendicitis rarely presents with UGI bleeding.