Differential Diagnosis for Hematemesis in a Patient with Hiatal Hernia

Single most likely diagnosis

• B. Cameron Lesion: This is a likely diagnosis given the patient's history of hiatal hernia. Cameron lesions are ulcers that occur in the mucosa of the stomach at the site of the hiatal hernia, and they can cause bleeding. The fact that no source of bleeding was identified after washing out the blood and the scope showed normal gastric and duodenum mucosa makes this a plausible option, as Cameron lesions can be difficult to visualize.

Other Likely diagnoses

• A. Dieulafoy Lesion: Although less common, Dieulafoy lesions are a possible cause of upper GI bleeding. They are characterized by a small, superficial ulceration with an exposed, large-caliber artery at its base. The lesion can be difficult to identify, especially if it is not actively bleeding at the time of endoscopy, which aligns with the scenario where no source was identified after clearing the blood.
• C. Gastric Antrum Ectasia (GAVE): Also known as watermelon stomach, GAVE is a rare cause of chronic gastrointestinal bleeding. It is characterized by ectatic vessels in the antrum of the stomach. While it's less likely given the acute presentation of hematemesis, it could be considered if other causes are ruled out.

Do Not Miss diagnoses

• Varices: Although the scope showed normal gastric and duodenum, varices could be a source of bleeding, especially in the context of a hiatal hernia. They might not always be visible, especially if they are small or if the bleeding has stopped. Missing varices could lead to severe consequences if not addressed.
• Mallory-Weiss Tear: This is a mucosal or submucosal tear at the junction of the stomach and esophagus that can cause significant bleeding. It might not be visible if the tear is small or has stopped bleeding by the time of endoscopy.

Rare diagnoses

• Gastric Arteriovenous Malformation (AVM): AVMs are rare vascular anomalies that can cause GI bleeding. They might be difficult to diagnose and could be considered if other, more common causes are ruled out.
• Hemobilia: This refers to bleeding into the biliary tree and is a rare cause of GI bleeding. It would be an unusual diagnosis in this context but could be considered if there are other suggestive findings or if common causes are excluded.