A 60-year-old woman presents at the Emergency Department complaining that she has been passing black, tarry stool since yesterday and had an episode of coffee-ground emesis some hours ago. It is the first time she has noticed these kinds of symptoms. Moreover, she reports episodes of epigastric pain on and off during the past week.
The patient has never undergone endoscopy. Her medical history includes diabetes mellitus, hypertension, hyperlipidaemia, gastro-oesophageal reflux disease (GORD), osteoarthritis and alcohol abuse. She admits that she occasionally uses nonsteroidal anti-inflammatory drugs (NSAIDs) to cope with episodes of pain caused by her osteoarthritis and that she took some in the past week.
On physical examination she is tachycardic (92 beats per minute) and hypotensive (82/57 mm Hg), but afebrile and her oxygen saturation level is normal. Her abdomen is mildly distended, with some tenderness during deep palpation and increased bowel sounds. Her blood test results at presentation are shown in Table 1. A variceal bleed was suspected, and an emergency upper gastrointestinal endoscopy was performed (see video).
Case Question 1
WHAT IS YOUR CLINICAL DIAGNOSIS?
A. Oesophageal melanoma
B. Oesophageal infection (e.g. CMV, HSV, Candidiasis)
C. Acanthosis nigricans
D. Acute oesophageal necrosis (AEN)
Case Question 2
WHICH OF THE CONDITIONS FROM THE PATIENT’S MEDICAL HISTORY IS NOT ASSOCIATED WITH THEIR DIAGNOSIS?
A. Diabetes mellitus
B. NSAID use
C. Alcohol abuse
Case Question 3
WHICH OF THE FOLLOWING MEASURES IS NOT RECOMMENDED FOR THE MANAGEMENT OF THIS PATIENT?
A. Nil per os
B. Aggressive fluid resuscitation
D. IV acid suppression with PPIs
E. Glycaemic control