Can you make the diagnosis?

Sam has been under a lot of stress at work.  He has a big project with a rapidly approaching deadline.  His heartburn has really flared up, and he notices he is getting a lot of acid reflux and burping.  He has been eating Tums and Rolaids to help with his symptoms.   He has also been taking a lot of Advil due to headaches he is getting during his long work days.

One night Sam gets home about 9 pm, has a cigarette and a martini, and goes to bed.  Around 2 am, he wakes up with severe stomach pain that radiates to his back.  He goes to the bathroom and vomits, and notices blood streaks in the toilet.

What does Sam have?

  1.  The stomach flu
  2.  A heart attack
  3.  A gallbladder attack
  4.  A stomach ulcer


If you guessed 4.  A stomach ulcer, you are correct!

Stomach ulcers (also known as peptic ulcer disease or gastric ulcer) can be preceded by heartburn symptoms and gnawing abdominal pain.  In early stages the pain can be relieved with eating.   Risk factors for stomach ulcers include smoking, NSAIDs (such as Advil), and alcohol.  There is also a type of bacterial infection that increases the risk of ulcers (H. pylori).   Bleeding can occur in 15% of stomach ulcers, and can cause bloody vomit or black stool (also called melena).

Ulcers are diagnosed by performing a scope into the stomach (egd or esophagogastroduodenoscopy).  Treatment for ulcers includes medicine that reduce the acid such as Proton Pump Inhibitors.  Patients who are found to have H. pylori bacterial infections are treated with antibiotics.

The stomach flu (gastroenteritis) is unlikely, as patients typically would have diarrhea, and would usually not have blood in their vomit.  Heart attacks usually cause chest pain, though they can cause pain in the upper abdomen in some patients, however again having blood in the vomit would be unlikely.  Gallbladder symptoms (cholelithiasis or cholecystitis) usually causes pain in the right upper part of the abdomen and can radiate to the back, are usually worse after eating, and would not typically cause vomiting blood.


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