Differential Diagnosis for Epigastric Tenderness

The patient's presentation of haematemesis, melaena, mild tenderness, and hypotension (BP 80/50) following a failed ERCP procedure for stone extraction suggests a serious complication. The differential diagnoses can be categorized as follows:

• Single Most Likely Diagnosis
  • A. Duodenal perforation: This is the most likely cause given the context of the ERCP procedure and the development of symptoms post-procedure. Duodenal perforation can lead to peritonitis, bleeding, and hypotension, aligning with the patient's presentation.
• Other Likely Diagnoses
  • B. Pancreatic injury: Injury to the pancreas during ERCP can cause pancreatitis, which might present with abdominal pain, including epigastric tenderness. However, the presence of haematemesis and melaena suggests a more acute and possibly bleeding complication.
  • C. Stone impaction: While stone impaction could cause pain, it is less likely to result in the severe symptoms of haematemesis, melaena, and hypotension seen in this patient.
• Do Not Miss Diagnoses
  • These are diagnoses that might not be the first consideration but are critical due to their potential severity and impact on management:
    • Aorto-enteric fistula (though rare and more commonly associated with previous aortic grafting): This could present with gastrointestinal bleeding and is a life-threatening condition.
    • Massive hemorrhage from an ulcer or vascular injury: Given the ERCP context, any injury to nearby vessels could lead to significant bleeding.
• Rare Diagnoses
  • Other rare complications of ERCP, such as cholangitis or liver injury, could potentially cause epigastric tenderness but are less likely given the specific symptoms of bleeding and hypotension.
  • Pseudoaneurysm formation: A rare but possible complication following ERCP, especially if there was instrumentation near major vessels.

Each of these diagnoses should be considered in the context of the patient's clinical presentation and the procedure that was performed. Immediate imaging and possibly reintervention may be necessary to address the cause of the epigastric tenderness and associated symptoms.