Mr. William Johnson is a 42-year-old CEO who presents to the emergency room complaining of the passage of black stools x 3 days and an associated lightheadedness. He also relates that he cannot keep up with his usual schedule because of fatigability. Upon further questioning he states that his stools are not only black, but are sticky and malodorous. He further complains of recent worsening of a chronic epigastric burning which had been a problem off/on for years. He had doubled his usual dose of Tums without significant relief of the burning. He has 2-3 martinis at lunch and another cocktail before dinner. He takes NSAIDS as needed for back pain and recently started on one aspirin per day for cardiac prophylaxis. He smokes two packs of cigarettes per day and an occasional cigar. He was told of an ulcer in the distant past but had no specific evaluation or treatment for same.
Mr. Johnson has been treated for hypertension for eight years but denies any known cardiac history. His weight is stable to increased and he claims to have an excellent appetite. He has a normal bowel habit and has not had prior black stools. He has had no abdominal surgery and denies bleeding tendencies or prior transfusion.
Patients relevant medical history/examination findings:
Facial pallor and cool, moist skin are noted.
Peripheral pulses are present but are rapid and weak.
The abdomen reveals a rounded abdomen. Bowel sounds are hyperactive. There is moderate tenderness in the epigastrium.
Hemoglobin 9gm/dL, hematocrit 27%
1. What is most likely diagnosis based on the information listed? Provide a strong rationale for your answer.
2. What makes the stool black?
3. A nasogastric tube was placed by the ER resident. What would you expect to see in the aspirate from the tube?
4. What will be another ideal procedure to confirm the location of the problem, and why?
5. What treatments might be recommended to the patient, and why?