A patient presents with sudden onset of hematemesis. He has been taking aspirin for his arthritis and drinks alcohol occasionally. He gives a history of occasional abdominal pain. On examination, there is no abdominal mass or tenderness. What is the likely diagnosis?

Explanation

## Correct Answer: D. Peptic ulcer Peptic ulcer disease (PUD) is the most likely diagnosis given the clinical presentation and risk factors. The patient has **two major risk factors**: chronic aspirin use (a potent NSAID that inhibits prostaglandin synthesis, reducing mucosal protection) and occasional alcohol consumption (both irritate gastric mucosa). The key discriminating feature is the **absence of abdominal mass or tenderness on examination**, which rules out complications like perforation with peritonitis. The sudden onset of hematemesis with a history of occasional abdominal pain is classic for PUD—the pain may have been mild or intermittent before bleeding occurred. NSAIDs account for approximately 60% of PUD cases in India (second only to H. pylori), and aspirin is a common culprit in elderly patients with arthritis. The bleeding in PUD typically occurs when the ulcer erodes into a blood vessel, presenting acutely without preceding severe peritoneal signs. This presentation—risk factors + hematemesis + benign abdominal exam—is pathognomonic for PUD rather than other causes of upper GI bleeding. ## Why the other options are wrong **A. Mallory-Weiss tear** — Mallory-Weiss tears classically present with hematemesis **after forceful vomiting or retching** (often in alcoholics with hyperemesis). This patient has no history of vomiting preceding the hematemesis, and the presence of chronic abdominal pain points to a structural lesion (ulcer) rather than a mucosal tear. Mallory-Weiss bleeding is typically self-limited and mild; massive hematemesis is less common. **B. Esophagitis** — Esophagitis (reflux, infectious, or caustic) presents with **dysphagia and odynophagia** as primary symptoms, not hematemesis as the presenting complaint. While esophagitis can bleed, it is rare and usually occurs in severe cases (e.g., CMV in immunocompromised). The patient's history of abdominal pain (not chest pain or dysphagia) and NSAID use strongly favor a gastric/duodenal source over esophageal pathology. **C. Esophageal varices** — Esophageal varices require **portal hypertension** (cirrhosis, portal vein thrombosis, etc.). This patient has no clinical signs of chronic liver disease, no mention of jaundice, ascites, or spider angiomata, and no history of alcohol abuse (only 'occasional' drinking). The benign abdominal exam and absence of stigmata of liver disease make varices unlikely. Varices typically present in patients with known or suspected cirrhosis. ## High-Yield Facts - **NSAIDs (especially aspirin) account for ~60% of PUD cases** in India, second only to H. pylori; mechanism is inhibition of prostaglandin-mediated mucosal protection. - **Peptic ulcer bleeding without peritoneal signs** indicates erosion into a blood vessel without perforation; perforation would present with acute peritonitis and rigid abdomen. - **Mallory-Weiss tears require preceding forceful vomiting/retching**; absence of this history makes PUD more likely in hematemesis. - **Esophageal varices require portal hypertension**; absence of cirrhosis stigmata (jaundice, ascites, spider angiomata) rules out varices in this patient. - **PUD pain is often epigastric and intermittent**, may improve with food (gastric ulcer) or antacids; bleeding occurs when ulcer base erodes into a vessel. ## Mnemonics **PUD Risk Factors (NSAID-dominant in India)** **H-A-N-C**: H. pylori, **A**spirin/NSAIDs, **N**icotine, **C**orticosteroids (with NSAIDs). In India, NSAIDs rival H. pylori; always ask about chronic NSAID use in elderly patients with arthritis. **Upper GI Bleed Differential by Preceding Event** **Vomiting → Mallory-Weiss**; **Pain + Bleed → PUD**; **No Symptoms + Bleed → Varices**. This patient has pain history, so PUD is top choice. ## NBE Trap NBE may pair "hematemesis + alcohol" to lure students toward esophageal varices, overlooking that occasional alcohol use without cirrhosis stigmata does not cause varices. The NSAID history is the key discriminator that NBE expects students to weigh heavily. ## Clinical Pearl In Indian outpatient practice, NSAID-induced PUD is increasingly common in elderly patients self-medicating for arthritis without gastroprotection. Always prescribe a proton-pump inhibitor (PPI) with chronic NSAIDs; if bleeding occurs, endoscopy with hemostasis (adrenaline injection, heater probe) is the gold standard, followed by high-dose PPI infusion and H. pylori eradication if positive. _Reference: Bailey & Love Ch. 65 (Peptic Ulcer Disease); Harrison Ch. 297 (Gastrointestinal Bleeding)_