Cases from the Osler Medical Service at Johns Hopkins University

Presenting features

A 41-year-old man with a past history of alcohol abuse, drug abuse, and smoking (>40 pack-years) presented with chronic epigastric pain and weight loss. During the preceding year, the epigastric pain had worsened progressively and was exacerbated by eating. For the past 3 months, his nausea and vomiting had worsened so that he was no longer able to tolerate solid food. Consequently, he had lost 50 lbs in 1 year. During the 3 weeks before admission, he had daily subjective fevers but no night sweats. He denied any melena, hematemesis, jaundice, or changes in stool color or consistency.His past medical history was remarkable for an episode of massive hematemesis, for which he was admitted to another hospital 3 months ago and found to have a bleeding gastric ulcer. Despite treatment with a proton pump inhibitor, his abdominal pain, nausea, and vomiting worsened after dis-charge. He stopped drinking alcohol after that hospitalization, and he stopped using intravenous drugs 1 month before this admission.On physical examination, the patient appeared wasted. His vital signs were notable for a normal blood pressure with resting tachycardia and an orthostatic increase in pulse rate. His jugular veins were flat. Cardiac and respiratory examinations were normal. The abdominal examination revealed guarding in the epigastric region with hypoactive bowel sounds and no rebound tenderness. His stool was guaiac negative. Laboratory studies revealed a total white blood cell count of 4180/mm³, a hematocrit of 33.1%, a platelet count of 239,000/mm³, a total protein level of 8.3 g/dL, an albumin level of 3.7 g/dL, and antibodies to human immunodeficiency virus (HIV). A computed tomographic scan of the abdomen showed thickening of the antrum with large gastric folds.What is the diagnosis?