EMQ: 1
Haematemesis and Melaena
a)
Mallory-Weiss tear
b)
Duodenal ulcer
c)
Oesophageal varices
d)
Gastric ulcer
e)
Dieulafoy lesion
f)
Gastric carcinoma
g)
Gastritis
h)
Oesophagitis
i)
Aortoenteric fistula
j)
Barrett’s oesophagus
Select the most likely diagnosis from the list above for
the following clinical scenarios:
1) A middle aged, obese female who has been having
pruritus for a long time presents with haematemesis and melaena. On
examination she has xanthelasma, no signs of chronic hepatocellular failure,
moderate splenomegaly
Answer: c) Oesophageal varices
In a middle-aged lady with a history of pruritus in
relation to a gastrointestinal problem, one should think of primary biliary
cirrhosis (PBC). The fact that she has xanthelasma is further evidence in
favour of this. The lack of signs of hepatocellular failure with evidence of
portal hypertension (splenomegaly) would also be in favour of this. The most
likely complication of PBC that would present with haematemesis and melaena
would be bleeding oesophageal varices.
2) A 75-year-old male with a history of anorexia and
weight loss presents with haematemesis and melaena. On examination he looks
cachectic and on palpation of the abdomen a hard, craggy liver is felt.
Answer: f) Gastric carcinoma
In an elderly patient with anorexia and weight loss, one
should consider gastric cancer. The fact that he is cachectic would be further
evidence in favour of this diagnosis. The finding of a hard craggy liver would
support this, as this finding would suggest liver metastases.
3) A 24-year-old male who has been on an alcoholic binge
presents wit haematemesis following a period of prolonged vomiting. On
examination he is inebriated but there is no cardiovascular instability and
his haemoglobin is within normal limits.
Answer: a) Mallory-Weiss tear
A young man presenting with vomiting after an alcoholic
binge should make one infer that there is no underlying medical condition.
Prolonged vomiting followed by haematemesis is suggestive f a Mallory-Weiss
tear and the fact that there is no cardiovascular instability nor a drop in
haemoglobin should also point to this diagnosis.
4) A 50-year-old sales representative who has been
complaining of abdominal discomfort of several months’ duration .the
discomfort is relieved by meals but wakes him up form his sleep. He presents
with a 3-day history of melaena.
Answer: b) Duodenal ulcer
The history of abdominal discomfort relieved by meals and
nocturnal discomfort is suggestive of a duodenal ulcer. The age group and the
fact that he has a presumably stressful job are also factors in favour of this
diagnosis.
5) A 78-year-old male who has had a repair of an
abdominal aortic aneurysm presents with melaena, tachycardia a fall in blood
pressure and is found to be anaemic.
Answer: i) Aortoenteric fistula
The history of aortic aneurysm repair should make on
suspect that the pathology is in relation to this. Melaena with cardiovascular
in stability and anaemia should further this suspicion.
Revision Tip
Look up ACES for PACES
page 287 for a classification of the causes of haematemesis
