Gastrointestinal Bleeding 299278.A 62-year-old man with a history of hypertension presents to the ED
with severe constant mid-epigastric pain for the past hour. Over the last
several months, he has had intermittent pain shortly after eating, but never
this severe. He states he now has generalized abdominal pain that began
suddenly about 15 minutes ago. He has no history of trauma, has never had
surgery, and takes no medications. His vitals include a HR of 115 beats per
minute lying supine, increasing to 135 when sitting up, BP of 170/105 mm Hg
supine, falling to 145/85 mm Hg when sitting up. He appears pale. His
abdomen is rigid and diffusely tender with guarding and rebound. Bowel
sounds are absent and stool hemoccult is positive. The white blood cell
(WBC) count is 8500/μL, hemoglobin 8.5 mg/dL, hematocrit 27%, and
platelets 255/μL. Which of the following is the most likely diagnosis?
a. Boerhaave syndrome
b. Perforated gastric ulcer
c. Abdominal aortic aneurysm (AAA)
d. Inflammatory bowel disease (IBD)
e. Diverticulosis
279.A 60-year-old man with a history of alcohol abuse presents to the ED
with hematemesis for 1 day. He denies abdominal or chest pain. On physical
examination, his eyes appear reddened which he attributes to having drunken
heavily the night before (he also reveals vomiting several times after this
recent binge). Vital signs are: HR 115 beats per minute, BP 130/85 mm Hg,
RR 18 breaths per minute, and temperature 99.5°F. Chest radiograph is
unremarkable. Laboratory results reveal a WBC 10,000/μL, hemoglobin
14 mg/dL, hematocrit 40%, and platelets 210/μL. Which diagnosis is endo-
scopic evaluation most likely to confirm?
a. Esophageal varices
b. Boerhaave syndrome
c. Curling ulcer
d. Perforated gastric ulcer
e. Mallory-Weiss tear