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Question

47yo man presents to the emergency department after an episode of hematemesis at the end of a 2 day alcoholic binge. He reports drinking 1-3 handles of vodka over the weekend after his 14 consecutive day, third shift schedule every month at the local manufacturing plant. He reports moderate central chest pain, but denies shortness of breath. Vitals are BP-110/82 mmHg, HR-112, RR-14, O2-98%, and temp-99.2o. Physical exam is unremarkable, hemoccult is negative, and labs are below.

1. What are the three (3) main differentials you need to consider?
2. What is the most likely diagnosis based on exam and labs?

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Answer

1. Given the history and risk factors, the top three differentials you need to consider are variceal bleed, Mallory-Weiss tear, and Boerhaave’s syndrome.
2. The most likely of these is Mallory-Weiss tear. The unremarkable physical exam points away from Boerhaave’s as patients most commonly present with mediastinitis and, in some instances, sepsis. Other physical examination findings of Boerhaave’s include subcutaneous emphysema of the neck with crepitus and Hamman’s sign of medisatinal crunch on auscultation. Varices can self-tamponade after an acute bleed, but given the patient’s hemodynamic status being stable with a normal H/H and negative hemoccult also move this down the differential list.