What is the diagnosis for a patient with recurrent epigastric pain, occasional vomiting, and stool positive for blood and mucus?

Diagnosis: Peptic Ulcer Disease with Gastritis (Option D)

The correct diagnosis is peptic ulcer disease with gastritis, as the combination of recurrent epigastric pain, vomiting, and blood in the stool with positive fecal occult blood test indicates upper gastrointestinal bleeding from ulceration, not colonic pathology. 1

Why This is Peptic Ulcer Disease with Gastritis

Classic Presentation Matches PUD

• Recurrent epigastric pain over 1 year is the hallmark symptom of peptic ulcer disease, occurring in most symptomatic patients 2, 3
• Occasional vomiting accompanies peptic ulcer disease and suggests active disease 1, 4
• Blood in stool indicates gastrointestinal bleeding, which is the most common complication of duodenal ulcers, manifesting as occult blood or melena 1
• The positive fecal occult blood test confirms upper GI bleeding from ulceration 1

Critical Distinction: Upper vs. Lower GI Bleeding

• Blood from peptic ulcer disease typically presents as melena (dark, tarry stool) or positive occult blood testing, not bright red blood with mucus 1, 3
• The question states "blood and mucus" but in the context of epigastric pain and vomiting, this represents upper GI bleeding that has passed through the intestinal tract 1
• Normal stool analysis (presumably meaning no diarrhea or inflammatory markers) further supports upper rather than lower GI pathology 1

Why NOT the Other Options

Inflammatory Bowel Disease (Option C) - Incorrect

• IBD typically presents with diarrhea as the predominant symptom, not primarily vomiting 1, 5
• IBD involves colonic or terminal ileal pathology, not the epigastric location described 1
• The epigastric pain location and retrosternal symptoms are more consistent with upper GI pathology rather than the colonic involvement typical of IBD 1
• IBD would show inflammatory changes on stool analysis (elevated calprotectin, lactoferrin), which appears normal here 5

Irritable Bowel Syndrome (Option B) - Incorrect

• IBS does not cause blood in stool or positive fecal occult blood tests - this is an explicit alarm feature that excludes IBS 5
• IBS is a functional disorder that presumes absence of structural or biochemical abnormalities 5
• Blood in stool mandates investigation for organic disease, not functional disorders 5

Abdominal Migraine (Option A) - Incorrect

• Abdominal migraine does not explain occult blood in stool or systemic signs 1
• Typically presents with periumbilical rather than epigastric pain 1
• This is a diagnosis of exclusion after ruling out organic pathology 1

Immediate Management Priorities

Warning Signs Requiring Urgent Action

• Fever and tachycardia raise concern for perforation, which carries mortality rates up to 30% if treatment is delayed 1, 6
• Sudden severe epigastric pain with abdominal rigidity indicates perforation requiring immediate surgical consultation 1, 6
• Hemorrhage occurs in 73% of complicated peptic ulcer cases with 30-day mortality of 8.6% 1

Diagnostic Workup

• Upper endoscopy is the first-line diagnostic and therapeutic investigation, allowing direct visualization of ulcers, histopathological confirmation, and H. pylori testing 1
• Complete blood count to assess for anemia from chronic bleeding 6
• Test for Helicobacter pylori infection (present in ~42% of peptic ulcer patients) 1, 2

Initial Treatment

• Start high-dose proton pump inhibitor therapy immediately (omeprazole 20-40 mg once daily) while awaiting endoscopy 6
• Discontinue any NSAIDs if being used (cause 36% of peptic ulcer cases) 1, 3

Common Pitfall to Avoid

Do not mistake upper GI bleeding (presenting as occult blood or melena) for inflammatory bowel disease simply because "blood and mucus" are mentioned - the epigastric location, vomiting pattern, and 1-year recurrent course point definitively to peptic ulcer disease 1, 3