A 14 years girl with abdominal pain and blood in vomit for 1 day the differential diagnosis is
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Differential Diagnosis: 14-Year-Old Girl with Abdominal Pain + Hematemesis (Blood in Vomit)
This is a upper GI bleeding (UGIB) presentation in an adolescent. The combination of abdominal pain + hematemesis narrows the differential considerably compared to painless bleeding. Here is a systematic breakdown:
Most Common (Likely) Causes in Adolescents
| Diagnosis | Key Features |
|---|---|
| Gastritis / H. pylori gastritis | Epigastric burning pain, nausea, history of NSAID use, H. pylori infection common in this age group |
| Peptic Ulcer Disease (PUD) | Epigastric pain, may be relieved by food; H. pylori or NSAID-related |
| Mallory-Weiss Tear | Longitudinal mucosal tear at gastro-esophageal junction after forceful vomiting; preceded by retching |
| Esophagitis | Heartburn, dysphagia, acid reflux; GERD-related |
"The adolescent will describe epigastric burning pain in a pattern more typical of adult presentations." - Tintinalli's Emergency Medicine
Less Common but Important Causes
| Diagnosis | Key Features |
|---|---|
| Esophageal / Gastric Varices | History of liver disease, portal hypertension (e.g., biliary atresia, cirrhosis); massive painless or painful bleeding |
| Coagulopathy / Bleeding Diathesis | Easy bruising, prolonged bleeding elsewhere, underlying hematologic disorder (von Willebrand, thrombocytopenia) |
| Crohn's Disease | Chronic abdominal pain, diarrhea, weight loss, perianal lesions, aphthous ulcers |
| Toxic / Caustic Ingestion | History of ingesting corrosives, medications (aspirin, NSAIDs, iron, steroids) |
| Bowel Obstruction | Vomiting, absent bowel sounds, distension |
| Henoch-Schonlein Purpura (HSP/IgA vasculitis) | Purpuric rash on lower limbs/buttocks, joint pain, abdominal pain, hematuria |
| Vascular Malformation / Dieulafoy's Lesion | Rare; sudden, massive bleeding from an aberrant submucosal vessel |
| GI Stromal Tumors | Rare but must be considered in adolescents with unexplained GI bleeding |
| Foreign Body | History of ingestion |
Symptom Complex Guide
Based directly on Table 134-3 from Tintinalli's Emergency Medicine:
- Hematemesis + abdominal/epigastric pain --> Peptic ulcer disease, H. pylori gastritis, esophagitis/gastritis, coagulopathy
- Hematemesis + underlying systemic disease --> Esophageal varices, inflammatory bowel disease
- Vomiting + hematochezia + abdominal pain --> Intussusception, malrotation/volvulus, Henoch-Schonlein purpura, ischemic bowel
Do Not Miss - Red Flags Requiring Urgent Action
- Esophageal varices - massive hemorrhage, hemodynamic instability
- Coagulopathy - check PT/INR/APTT, CBC
- Bowel obstruction / ischemia - rigid abdomen, peritoneal signs
- HSP - look for rash, joint swelling, proteinuria
Non-GI Sources to Exclude First
Before assuming GI origin, always rule out:
- Epistaxis (swallowed blood from nose)
- Oropharyngeal/dental bleeding (swallowed blood)
- Pulmonary source (hemoptysis mistaken for hematemesis)
Summary by Priority for a 14-Year-Old Girl
- H. pylori gastritis (most common cause of upper GI bleeding in adolescents)
- Peptic ulcer disease (NSAID use? Stress?)
- Mallory-Weiss tear (forceful vomiting?)
- Reflux esophagitis
- Esophageal varices (if liver disease or portal hypertension present)
- Coagulopathy (bleeding diathesis)
- IBD / Crohn's disease
- HSP / vasculitis
- Toxic ingestion (medication history)
- GI stromal tumors / vascular malformations (rare)
Initial workup should include: CBC, coagulation studies (PT/INR, APTT), metabolic panel, liver function tests, BUN/creatinine (elevated BUN with normal creatinine suggests UGIB), blood type & crossmatch, nasogastric lavage to confirm upper GI source, and urgent gastroenterology/endoscopy referral.
- Tintinalli's Emergency Medicine: A Comprehensive Study Guide, Table 134-1 & 134-3
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