60ish year old man, sent in by his PCP to our ER for hemetemasis. PCP thinks he’s probably got a GI bleed, and notes in his clinic visit, “risks include smoking & prednisone”. The patient had been to another ED nearby the night before for chest pain, lots of labs, EKGs and xrays done with no firm explanation and he was sent home.

WHen I see the patient, he has a rim of bright red blood around his lips, almost like lipstick. I ask him what’s bothering him the most. “I need pain medicine!” he says. I ask more questions. His low back has been hurting on and off for about 3 weeks, that’s a new problem for him. He keeps asking for pain medicine. His belly hurts just a little bit. He is not bothered by the blood, though, and is pretty sure he vomited it, and didn’t cough it up. It only happened once.

Other History: High blood pressure, emphysema, AAA repair 1996. Still has his appendix and gallbladder. No history of heart disease, that he knows of. No history of diabetes.

Physical exam: Vital signs are unremarkable. Patient looks a little dehydrated. Curled up in bed, but denies problems aside from his back pain. Neck/carotids unremarkable. Heart is regular and strong. Lungs with wheezes. ABdomen is soft with a firmish mass in the left mid abdomen, without pulsations. Non tender. He has bowel sounds. Rectal exam is brown, just trace heme positive on testing.

What’s in your differential at this point? What ancillary studies would you order?

I’ll post the results of blood work & images next time, until then, let me know what you’re considering and what you would do next if he were your patient.