The correct answer is F. This patient has a history and physical exam consistent with a history of alcoholism and hepatitis C. These are both risk factors for cirrhosis of the liver. Upper gastrointestinal bleeding in the form of bloody emesis should immediately bring the thought of variceal hemorrhage to mind. Endoscopy is necessary to evaluate for variceal hemorrhage or peptic ulcer disease.
This patient is at a high risk for cirrhosis (choice A) and already has physical exam findings of cirrhosis such as ascites and a caput medusa. Cirrhosis in itself is insidious, leading to liver failure, an immunocompromised state, and a higher risk for hepatocellular carcinoma. A consequence of cirrhosis is portal hypertension and esophageal varices. This is the most urgent issue that needs to be addressed.
Delirium tremens (choice B) may be life threatening if untreated, but this patient has no symptoms of alcohol withdrawal or seizures at this time.
Esophageal cancer (choice C) is in the differential for upper gastrointestinal bleeding, but in this patient with risk factors for cirrhosis, variceal bleeding is the first concern.
Gastric carcinoma (choice D) is in the differential for upper gastrointestinal bleeding, but in this patient with risk factors for cirrhosis, variceal bleeding is the first concern.
Portal vein thrombosis (choice E) may be associated with systemic or local infection such as cholangitis, adjacent suppurative lymphadenitis, pancreatitis, and a hepatic abscess. It is also seen in patients in hypercoagulable states. Portal vein thrombosis occurs in 10% of patients with cirrhosis and frequently accompanies hepatocellular carcinoma. Portal vein thrombosis is not symptomatic itself, but it can lead to complications such as esophageal varices. The urgent issue that needs to be addressed in this patient is the evaluation of the hematemesis.
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