1. Case study Mr. Wang, a 64-year-old male, presented with nausea and coffee ground emesis in your department. In the past 1 month, he suffered from recurrent epigastric pain accompanied with bloating, belching and anorexia

2. 1. What are the key symptoms presented in this case? Hematemesis Epigastric pain

3. 2. What are the possible etiologies? 1)peptic ulcer 2)hemorrhagic gastritis 3)esophageal or gastric varices 4)gastric cancer

4. Upper GI tract bleeding –Esophagus, GERD, Tumor, Mallory-Weiss tear, radiation injury, chemical injury –Gastric duodenal Diseases, vascular anomalies, hemangioma, cancer of gastric remnant, ancylostomiasis, gastric or duodenal Crohn’s disease, TB Organ or tissue adjacent to upper GI tract –Biliary system, stone, tumor –Pancreatic disease involves duodenum, Tumor or pancreatitis with ruptured abcess –Rupture of aortic, hepatic or splenic aneurysm –Mediastinal Tumors or abscess Systemic diseases –Hematologic diseases, leukemia, hemophilia –Uremia –Connective tissue diseases, vesculitis –AID, epidemic hemorrhagic fever, leptospirosis

5. 3. For the diagnosis, what details do you want to ask the patient, such as any risk factors, characteristics of these symptoms and any accompanying symptoms?

6. Risk factors or history: smoke, alcohol, drugs, poisoning, past surgical history, past medical history, etc Characteristics of these symptoms: hematemesis: frequecy, color, amount hypovolemia or shock: oliguria, pale, fatigability, dizziness, dyspnea, palpitation, sweating epigastric pain: PQRST Accompanying symptoms: chills, fever, jaundice, subcutaneous hemorrage

7. According to Mr. Wang’s complaint, he had been suffering from recurrent epigastric burning pain accompanied with bloating, belching and anorexia for 1 month, but without weight loss. After hematemesis (about 200 ml coffee ground emesis) accompanied with weakness and dizziness, he came to your department. The patient did not vomit vigorously before hematemesis. There was no history of alcohol abuse or intake of NSAIDs, nor experience of surgery or trauma. He also denied the history of acute or chronic viral hepatitis.

8. 4.What do you want to do next? PE

9. Physical examination: Temperature: 37.6 ℃, Blood Pressure: 90/60mmHg. The patient looks pale. There is no jaundice of his skin and sclerae. No signs of bleeding on his skin. Neither spider anginoma nor liver palms are found. Superficial lymph nodes are not palpable. The heart rate is 96 per minute with regular rhythm, without any murmur. Chest auscultation: normal sounds, no rales. The abdomen is flat and soft; no dilated vein; no visible intestinal pattern and peristaltic wave. There is mild tenderness beneath the xiphoid process, without muscle guarding and rebound tenderness. There are no palpable liver, spleen or other masses. There is no shifting dullness. Bowel sounds: 8 times/min. There is no edema in the lower extremities.

10. 5.Could you find any clues from above information that might benefit for your diagnosis?  M, 64  Symptoms: Hematemesis once several hours ago and epigastric pain for 1 month  Signs: Temperature: 37.6 ℃ ; Blood Pressure: 90/60mmHg; mild tenderness beneath the xiphoid process; Bowel sounds: 8 times/min peptic ulcer hemorrhagic gastritis esophageal or gastric varices gastric cancer

11. 6.Which following examinations should you order for the patient? Why? - Occult blood test of vomitus or stool - Blood routine test - Liver function test - Hepatic virus - Chest X ray - Abdominal ultrasound - emergency gastroscopy

12. Mr.Wang came back 3 hours later. The results are as follows: Occult bleed test of vomitus: ++++ WBC 11.5*10 9 /L (4-10 ) *10 9 /L ； RBC3.50*10 12 /L (4- 5.5)*10 12 /L ； Hb 80g/L(120-160g/L) ； PLT: 120*10 9 /L (100-300 ) *10 9 /L Liver function test: Normal Heptic virus: HbsAg (-) Abdominal ultrasound: Fatty liver; the gallbladder wall is slightly thickened; the spleen and pancreas have a normal shape and size. Emergency gastroscopy: Gastric angular ulcer; Chronic gastritis; Hp (Helicobacter Pylori) +

13. 7.According to the presentation,what is the most possible diagnosis? And why? Gastric ulcer; Chronic gastritis Gastric cancer?  M, 64  Symptoms: Hematemesis once several hours ago and epigastric pain for 1 month  Signs: Temperature: 37.6 ℃ ; Blood Pressure: 90/60mmHg; mild tenderness beneath the xiphoid process; Bowel sounds: 8 times/min  Investigations: Occult bleed test of vomitus: ++++; Emergency gastroscopy: Gastric angular ulcer; Chronic gastritis; Hp (Helicobacter Pylori) +