Recurrent Peptic Ulcer with Hematemesis in a 30-Year-Old Female

Case at a Glance

A 30-year-old female with a history of peptic ulcer disease presented with recurrent dyspepsia and two episodes of hematemesis, concerning for an active upper gastrointestinal bleed.

Patient's Story

The patient is a 30-year-old female who was diagnosed with a peptic ulcer via endoscopy approximately 10 years ago. She has recently experienced a return of symptoms, including stomach irritation, particularly after consuming coffee or spicy foods. Over the past few weeks, she has had two distinct episodes of vomiting what she described as 'bloody' vomit. The most recent episode occurred after a day of sun exposure and consumption of whiskey. Following this, she experienced persistent stomach pain.

Initial Assessment

The patient presented with a chief complaint of epigastric pain and hematemesis. Her past medical history is significant for peptic ulcer disease. She reported no current medications. On initial inquiry, she identified dietary triggers (caffeine, spicy food) and alcohol as exacerbating her symptoms. The primary concern was to rule out an active upper gastrointestinal (GI) bleed, given her history and the description of the emesis, which had a 'coffee-ground' appearance consistent with digested blood.

The Diagnostic Journey

Given the high suspicion for an upper GI bleed, the patient was advised to seek immediate medical evaluation. The diagnostic workup included a complete blood count (CBC) to assess for anemia from blood loss and a basic metabolic panel. A physical examination revealed tenderness in the epigastric region. The definitive diagnostic procedure was an esophagogastroduodenoscopy (EGD). The EGD revealed inflammation of the gastric lining (gastritis) and identified a 1.5 cm ulcer in the duodenal bulb with stigmata of recent bleeding.

Final Diagnosis

Bleeding Duodenal Ulcer secondary to Recurrent Peptic Ulcer Disease.

Treatment Plan

The patient was started on an intravenous proton pump inhibitor (PPI) infusion to suppress acid production and promote healing. Biopsies taken during the EGD were tested for Helicobacter pylori, which returned positive. A treatment plan was initiated consisting of a 14-day course of quadruple therapy for H. pylori eradication. The patient was counseled on strict avoidance of NSAIDs, alcohol, and other dietary irritants like caffeine and spicy foods. After discharge, she was prescribed a high-dose oral PPI to be taken for 8-12 weeks.

Outcome and Follow-up

The patient's symptoms of pain and nausea resolved with treatment. She tolerated the H. pylori eradication therapy well. She was scheduled for a follow-up appointment in 4 weeks to assess symptom resolution and ensure adherence to the PPI regimen. A repeat EGD was planned after completion of therapy to confirm ulcer healing and eradication of H. pylori. The patient was educated on the chronic nature of peptic ulcer disease and the importance of long-term lifestyle modifications to prevent recurrence.