QuestionSBA
QuestionChoice
Symptoms of progressive dysphagia and weight loss in a smoker are always highly suggestive of oesophageal malignancy. Unfortunately, these malignancies can bleed as they advance and cause haematemesis as seen here. Most often it is a small volume of blood, except as a preterminal event with erosion of major vessels. The bleeding may be recurrent until the malignancy is effectively managed.
10005331
a
Oesophageal malignancy
QuestionChoice
Similar to gastric ulcers, this diagnosis usually has known antecedent reflux-type symptoms. It presents with a smaller volume of fresh blood, often streaking vomit. Medications are frequently responsible which include tetracycline antibiotics, NSAIDs and bisphosphonates.
10005335
e
Oesophagitis
QuestionChoice
This occurs following bouts of repeated vomiting, often secondary to acute alcohol intoxication.
10005334
d
Mallory-Weiss tear
QuestionChoice
Varices usually present with a much larger volume of fresh blood. They are often associated with haemodynamic compromise too. Varices may stop spontaneously but re-bleeds are common until they are appropriately managed. They arise through portal hypertension, most commonly secondary to cirrhosis, not present in this case.
10005333
c
Oesophageal varices
QuestionChoice
This is a fairly rare diagnosis with duodenal ulcers being four times more common. Gastric ulcers may well cause frank haematemesis or may present with altered blood mixed with vomit. There are usually prodromal features of dyspepsia and/or medication culprits such as NSAIDs, steroids or SSRIs though. Alcohol is another risk factor not present in this case.
10005332
b
Gastric ulcer
Concept
Chapter
2693
4390
Upper GI bleed
Topic
136
Gastroenterology
13613
A 68-year-old male presents to the emergency department after four recurrent episodes of haematemesis. He reports each episode was approximately two tablespoons of fresh red blood. On further questioning, he reveals an eight-week history of progressive dysphagia to solids, especially meat, and associated fatigue. He denies abdominal pain. He has a past medical history of diverticulosis and hypertension. His medications are ramipril only. He is a long-term smoker of ten cigarrettes per day and he does not drink alcohol.

Which of the following is the most likely cause of this patient’s haematemesis?
a