Differential Diagnosis for Black Emesis in a 43-year-old Female

The patient presents with an episode of black emesis, a history of GERD, and current medication including omeprazole and Pepcid. The differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis
  • Gastroesophageal Reflux Disease (GERD) exacerbation: Given the patient's history of GERD and the recent bad episode, it's plausible that the black emesis is related to a severe GERD flare-up, possibly with some degree of esophageal irritation or minor bleeding, although the absence of coffee ground appearance makes significant bleeding less likely.
• Other Likely Diagnoses
  • Mallory-Weiss Tear: 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, and the blood may appear black when vomited. The patient's history of severe GERD could contribute to the likelihood of such a tear.
  • Peptic Ulcer Disease: Although the patient is on medications that reduce stomach acid, peptic ulcers can still occur or bleed, leading to black emesis. The presence of omeprazole and Pepcid in her regimen suggests an attempt to manage acid production, but ulcers can be a complication of long-standing GERD or inadequate acid suppression.
• Do Not Miss Diagnoses
  • Upper Gastrointestinal Bleed: This is a critical diagnosis to consider, as it can be life-threatening. The black emesis could be a sign of bleeding from the upper GI tract, which requires immediate attention. Conditions such as ulcers, varices, or even a tear could be the source.
  • Esophageal Perforation: Although less common, an esophageal perforation could present with severe chest pain and potentially black emesis if there's associated bleeding. This condition is medical and surgical emergency.
• Rare Diagnoses
  • Gastric Cancer: While rare in this age group and without other specific risk factors or symptoms, gastric cancer could potentially cause black emesis due to bleeding from a tumor. This diagnosis would be considered if other more common causes are ruled out and if there are other suggestive symptoms or findings.
  • Dieulafoy's Lesion: A rare cause of GI bleeding, Dieulafoy's lesion is a small mucosal defect with an exposed, often large, caliber artery at its base. It can cause significant, sometimes life-threatening bleeding.

Orders and Medications in the Emergency Department

• Lab Tests: Complete Blood Count (CBC), Blood Urea Nitrogen (BUN), Electrolytes, Liver Function Tests (LFTs), and a type and screen in case blood transfusion is needed.
• Imaging: Consider a chest and abdominal X-ray to rule out free air under the diaphragm (indicative of perforation) and other complications. An upper endoscopy may be necessary for direct visualization of the esophagus, stomach, and duodenum to identify the source of bleeding.
• Medications:
  • Proton Pump Inhibitors (PPIs): Continue or increase the dose of omeprazole to maximize acid suppression.
  • Antacids: As needed for symptom management.
  • Fluid Resuscitation: If there's evidence of significant blood loss or dehydration.
  • Blood Transfusions: If the patient shows signs of significant blood loss or anemia.

Each of these steps is aimed at stabilizing the patient, identifying the cause of the black emesis, and managing the underlying condition effectively.