What is the differential diagnosis for a patient presenting with hematemesis and a history of esophagitis, hypertension, thrombocytosis, hyperlipidemia, and type 2 diabetes?

Differential Diagnosis for Hematemesis with History of Esophagitis

The differential diagnosis for hematemesis in this patient should prioritize erosive esophagitis as the most likely cause given the known history, followed by peptic ulcer disease, gastric erosions, and less commonly variceal bleeding or vascular malformations. 1, 2

Primary Diagnostic Considerations

Most Likely: Erosive Esophagitis

• Erosive esophagitis is a well-established cause of upper gastrointestinal bleeding and presents characteristically with hematemesis (86% of cases) more frequently than melena (38% of cases). 3
• Patients with esophagitis-related bleeding typically have less severe hemodynamic compromise, smaller decreases in hematocrit, and lower mortality compared to other causes of upper GI bleeding. 3
• The severity of esophagitis correlates with bleeding presentation—more severe esophagitis increases the likelihood of melena in addition to hematemesis. 3

Peptic Ulcer Disease

• Duodenal and gastric ulcers represent the most common causes of nonvariceal upper gastrointestinal bleeding overall. 1
• Risk factors in this patient include potential NSAID use (common with hypertension management), diabetes, and hyperlipidemia. 1
• Gastric ulcers specifically are associated with recurrent bleeding and require aggressive management. 4

Gastric Erosions and Gastroduodenal Lesions

• Gastric erosions are among the most frequent causes of upper GI bleeding and commonly present with hematemesis. 1, 2
• These lesions are often associated with medication use, stress, or metabolic conditions like diabetes. 1

Secondary Considerations

Mallory-Weiss Tears

• Mallory-Weiss tears occur from forceful vomiting or retching and are a recognized cause of hematemesis. 1, 2
• These typically present with bloody hematemesis rather than coffee-grounds emesis. 5

Variceal Bleeding (Lower Probability Without Cirrhosis)

• While esophageal varices are a major cause of upper GI bleeding, they require portal hypertension, typically from cirrhosis. 1
• Without documented liver disease or cirrhosis, variceal bleeding is unlikely in this patient despite the hypertension history. 4
• If varices were present, mortality would be significantly higher (30% vs. 10% for non-variceal causes). 6, 4

Vascular Malformations and Rare Causes

• Angiodysplasia and vascular malformations can cause upper GI bleeding but are less common. 1
• Dieulafoy lesion accounts for only 1-2% of acute upper GI bleeding cases. 1
• Gastric submucosal arterial collaterals are extraordinarily rare and typically associated with splenic artery thrombosis. 7

Critical Clinical Distinctions

Hematemesis Characteristics

• Bloody (fresh red) hematemesis suggests active, potentially more severe bleeding requiring urgent intervention, while coffee-grounds emesis indicates blood exposed to gastric acid. 8, 9
• However, bloody versus coffee-grounds appearance does not reliably predict mortality (6.6% vs. 9.3% respectively). 5
• The presence of both hematemesis AND melena significantly worsens outcomes compared to isolated hematemesis (composite endpoint 62.4% vs. 25.6% for bloody emesis). 5

Risk Stratification Based on Comorbidities

• This patient's diabetes and hypertension are independent risk factors for mortality in upper GI bleeding. 4
• Thrombocytosis is unusual and may suggest an underlying myeloproliferative disorder, though this does not directly cause hematemesis. 4

Common Pitfalls to Avoid

• Do not assume esophagitis causes only minor bleeding—it can present with significant hematemesis requiring hospitalization. 3
• Do not overlook medication history, particularly NSAIDs, antiplatelet agents, or anticoagulants that may contribute to bleeding. 2
• Do not delay endoscopy beyond 24 hours, as diagnostic and therapeutic success rates are highest within the first 36 hours of bleeding onset. 9, 6
• Do not assume coffee-grounds emesis is benign—it still requires full evaluation with endoscopy. 9