Differential Diagnosis for Upper GI Bleeding
The patient presents with upper GI bleeding and normal coagulation and investigations. Given the options, here's a categorized differential diagnosis:
Single Most Likely Diagnosis
- Mallory-Weiss Syndrome: This condition is characterized by tears in the mucous membrane or lining of the lower end of the esophagus, where it connects to the stomach. These tears can bleed, leading to upper GI bleeding. The syndrome is often associated with intense or prolonged vomiting, retching, or coughing but can also occur after anything that leads to a sudden increase in abdominal pressure, such as heavy lifting or severe straining during bowel movements. Given its relatively common presentation in the context of upper GI bleeding without other clear causes, it stands out as a likely diagnosis.
Other Likely Diagnoses
- Dieulafoy's Lesion: This is a rare but important cause of upper GI bleeding, characterized by a small, usually solitary mucosal defect with an exposed, often large caliber, artery at its base. It can cause significant bleeding due to the size of the artery involved. While less common than other causes of upper GI bleeding, its potential for severe bleeding makes it a consideration in cases without an obvious source.
- Peptic Ulcer Disease: Although not explicitly mentioned, peptic ulcers (gastric or duodenal) are a common cause of upper GI bleeding. The fact that coagulation studies are normal does not rule out this diagnosis, as most peptic ulcer bleeding is not due to coagulopathy but rather to the ulcer itself.
Do Not Miss Diagnoses
- Variceal Bleeding: This is a critical diagnosis to consider, especially if there's any suspicion of liver disease or portal hypertension. Variceal bleeding can be life-threatening and requires immediate intervention. Even if less likely given the normal investigations, missing this diagnosis could be catastrophic.
- Arteriovenous Malformation (AVM): AVMs are abnormal connections between arteries and veins, which can occur in the GI tract and cause bleeding. They are less common but can be a source of significant, sometimes recurrent bleeding.
Rare Diagnoses
- Gastric Antral Vascular Ectasia (GAVE): Also known as watermelon stomach, this condition is characterized by dilated small blood vessels in the stomach, which can cause chronic blood loss and iron deficiency anemia. It's a rare cause of upper GI bleeding but should be considered in cases where other diagnoses are ruled out.
- Hemobilia: This refers to bleeding into the biliary tree and is a rare cause of upper GI bleeding. It's often associated with trauma, tumors, or iatrogenic causes (e.g., after liver biopsy).
Each of these diagnoses has a different approach to management and treatment, emphasizing the importance of accurate diagnosis in guiding therapy.