Dysphagia and Epigastric Pain in an Adolescent Boy

Presentation

A 17-year-old previously healthy boy presents with a history of epigastric abdominal pain associated with some difficulty in swallowing for the past 3 days. He denies any emesis but reports nausea. The abdominal pain is localized to the epigastric area without any radiation. Pain is reported at 7 on a scale of 1 to 10. He denies any diarrhea but had noticed a few episodes of black tarry stool for the past 2 days. His sexual history is significant for oral sex with a single female partner, but he denies any genital or oral lesions. He was seen by his pediatrician 2 days ago. His pediatrician suspected a gastric ulcer and prescribed him pantoprazole, which the patient never obtained.

On presentation he has a temperature of 103°F (39.4°C) and appears mildly dehydrated. His vital signs are otherwise within normal limits. On physical examination the patient has dry lips and mucosa, but no oral lesions are noted. Mild epigastric tenderness without any rigidity or rebound tenderness is noted. Examination findings are otherwise normal. Initial laboratory evaluation shows a white blood cell count of 12,900/μL (12.9×10⁹/L), and the remainder of the blood cell count and metabolic panel are normal. The results of the antigen test for influenza, the heterophile antibody test for infectious mononucleosis, and the rapid streptococcal antigen test are negative. His CRP level is elevated to 12 mg/dL (120 mg/L). A computed tomographic scan …