A 37-year-old man presents with abdominal pain, mild nausea, and “dark stools.” The patient reports that over the past 6 months he has noticed abdominal pain that is only alleviated by eating. He has gained 6.8 kg (15 lb) during this time period. The patient denies alcohol or illicit drug use, but does report headaches for which he takes over-thecounter acetaminophen. Physical examination is unremarkable; however, fecal occult blood test (FOBT) is positive.
Which of the following is the most likely diagnosis?
A. Peptic ulcer diseasePeptic ulcer disease. This patient is presenting with melena (dark tarry stools) and abdominal pain. Given the patient’s history of alleviation of the abdominal pain with food, it is likely that his symptoms and GI bleeding are secondary to peptic ulcer disease (PUD), specifically duodenal ulcers. Duodenal ulcers are associated with weight gain and gastric ulcers are associated with weight loss. Furthermore, duodenal ulcers and gastric ulcers are both most commonly caused by H. pylori infections, but duodenal ulcers are almost entirely (greater than 95%) to be linked to H. pylori. Of note, PUD is the most common cause of upper GI bleeding. Diagnosis requires upper endoscopy. (B) Diverticulosis is usually asymptomatic; however, if it is associated with GI bleeding, it is typically bright red bleeding. (C) Colon cancer should always be considered, but this is a young patient and he does not present with weight loss. Similar to diverticulosis, colon cancer would present with bright red blood per rectum, unless it is a slow, right-sided GI bleed, which can be maroon colored or melenotic. (D) Mesenteric ischemia is accompanied by abdominal pain that is worse with eating. However, this patient’s abdominal pain improves with eating (making duodenal peptic ulcer disease the most likely diagnosis).