Differential Diagnosis for Hematemesis with Negative Endoscopy

• Single most likely diagnosis
  • Mallory-Weiss tear that has healed: This is a possible cause because the patient presented with hematemesis and a significant drop in hemoglobin, suggesting a significant upper GI bleed. The fact that the endoscopy was done on the 4th day after the bleed started and did not show any evidence of an ulcer, varix, or tear could indicate that the tear has healed, as Mallory-Weiss tears can resolve quickly.
• Other Likely diagnoses
  • Erosive gastritis: Although the endoscopy did not show ulcers, erosive gastritis could have caused the bleeding and might not have been visible or might have healed by the time of the endoscopy.
  • Dieulafoy's lesion: This is a rare cause of GI bleeding but can be difficult to diagnose if the lesion is small and not actively bleeding at the time of endoscopy.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Aorto-enteric fistula: Although rare, this condition can cause severe GI bleeding and is often fatal if not recognized and treated promptly. The absence of findings on endoscopy does not rule out this diagnosis.
  • Hemobilia or hemosuccus pancreaticus: These conditions involve bleeding into the biliary or pancreatic ducts, respectively, and can cause GI bleeding without visible lesions on standard endoscopy.
• Rare diagnoses
  • Vascular malformations or angiodysplasia: These can cause GI bleeding and might not be visible on a standard endoscopy, especially if they are not actively bleeding.
  • Gastrointestinal lymphoma or other malignancies: Although less common, these conditions can cause bleeding and might not be immediately apparent on endoscopy, especially if the bleeding site has healed or if the malignancy is not yet advanced enough to be visible.