A 27-Year-Old Man With Hyperemesis and Hematemesis

Gerard J. Fitzmaurice, BSc, MBBCh BAO; Robin Brown, MD, FRCS; Mark E. O'Donnell, DSEM, MFSEM, MRCS; Fionnuala Mone, MBBCh BAO; Angela McGreevy, MBBCh BAO


June 27, 2017

Physical Examination and Workup

Upon physical examination, the patient has a temperature of 99.5°F. He is in sinus tachycardia, with a heart rate of 130 beats/min, and his blood pressure is 118/82 mm Hg.

On examination, the patient is severely dehydrated and agitated, with tenderness to palpation noted in the upper chest and neck. The lungs are clear to auscultation, and heart sounds S1 and S2 are heard, with no murmurs or added sounds. His abdomen is soft, with a tender epigastrium.

The initial work-up includes laboratory investigations. The clinically significant results are as follows:

  • White blood cell count: 17.9 × 103 cells/µL (normal range, 4-11 x 103 cells/µL)

  • Sodium level: 147 mEq/L (normal range, 135-145 mEq/L)

  • Potassium level: 2.6 mEq/L (normal range, 3.5-5 mEq/L)

  • Blood urea nitrogen level: 14.5 mg/dL (normal range, 7-19 mg/dL)

  • Creatinine level: 1.71 mg/dL (normal range, 0.8-1.7 mg/dL)

Liver function test results are slightly deranged, with the main abnormality being an increased gamma-glutamyltransferase level of 716 U/L (normal range, 11-51 U/L). An ECG is performed and shows a prolonged QT interval, with ST depression in the inferior and anterolateral leads.

The patient is diagnosed with multiorgan failure caused by sepsis, and he is transferred to the high-dependency unit. He is treated with vigorous fluid resuscitation and broad-spectrum intravenous (IV) antibiotics. Further probing of the history reveals that he has vomited 30 times in the past 24 hours.

An erect posteroanterior chest radiograph is urgently obtained (Figure 1). An abnormality on the chest radiograph prompts CT of the chest (Figure 2) and the abdomen (not pictured).

Figure 1.

Figure 2.


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