Differential Diagnosis for Chest Pain, Hematemesis, and Hypovolemia
The combination of chest pain, hematemesis (vomiting blood), and hypovolemia (decreased volume of circulating blood) suggests a serious underlying condition that requires immediate medical attention. Here's a categorized differential diagnosis:
Single Most Likely Diagnosis
- Boerhaave's Syndrome: This is a severe form of esophageal rupture, often caused by forceful vomiting. It can lead to chest pain, hematemesis, and hypovolemia due to bleeding and fluid loss into the thoracic cavity. The acute onset of symptoms, especially after an episode of vomiting, makes this a highly plausible diagnosis.
Other Likely Diagnoses
- Peptic Ulcer Disease: Bleeding from a peptic ulcer can cause hematemesis and lead to hypovolemia if the bleeding is significant. Chest pain can be referred from the upper gastrointestinal tract. The presence of risk factors such as NSAID use, Helicobacter pylori infection, or a history of ulcers increases the likelihood.
- Esophagitis or Esophageal Ulcer: Inflammation or ulceration of the esophagus can cause chest pain and bleeding, leading to hematemesis. If the bleeding is substantial, it can result in hypovolemia.
- Gastroesophageal Reflux Disease (GERD): While less likely to cause severe bleeding, GERD can lead to esophagitis and potentially to bleeding, especially if there are complications like an esophageal ulcer.
Do Not Miss Diagnoses
- Aortic Dissection: Although less common, an aortic dissection can present with sudden, severe chest pain and, if there's involvement of the aorta near the esophagus or stomach, potentially with hematemesis. Hypovolemia could occur due to rupture into the thoracic cavity. This condition is life-threatening and requires immediate intervention.
- Pulmonary Embolism: A large pulmonary embolism can cause chest pain and, in rare cases, hematemesis if there's associated pulmonary infarction leading to bleeding. Hypovolemia might result from the systemic effects of a large embolism. This diagnosis is critical not to miss due to its high mortality rate if untreated.
- Myocardial Infarction: While myocardial infarction (heart attack) primarily causes chest pain, in rare instances, it can lead to hematemesis if there's associated stress ulceration or, very rarely, direct involvement of the gastrointestinal tract. Hypovolemia could result from cardiogenic shock.
Rare Diagnoses
- Dieulafoy's Lesion: A rare cause of gastrointestinal bleeding, Dieulafoy's lesion is a small, superficial ulceration with an exposed, large-caliber artery. It can cause significant bleeding leading to hematemesis and hypovolemia but is less likely to cause chest pain directly.
- Mallory-Weiss Syndrome: This condition involves tears in the mucous membrane or lining of the lower end of the esophagus, where it connects to the stomach. These tears can bleed, leading to hematemesis. While it can cause chest pain, it's less commonly associated with significant hypovolemia compared to other diagnoses listed.
Each of these diagnoses requires careful consideration based on the patient's history, physical examination, and diagnostic tests to determine the most appropriate treatment.