Which of the following is the most significant risk factor for development of this patient's condition?


#1

A 50-year-old plumber is admitted to the hospital through the emergency department because of hematemesis that began at home following dinner 1 hour ago. Medical history is significant for mild epigastric pain, for which he has not sought care. He has not had weight loss, but he occasionally has had dark stools. He takes hydrochlorothiazide for hypertension and over-the-counter ibuprofen for lumbar pain. He has no family history of gastrointestinal problems. None of his family members at home are ill. He recently worked on a clogged sewer line in a large chemical plant. He returned home 7 days ago from a vacation to a resort in Mexico. He drinks two beers nightly. The patient is 183 cm (6 ft) tall and weighs 91 kg (200 lb); BMI is 27 kg/m2. Vital signs on admission are temperature 36.1°C (97.0°F), pulse 110/min, respirations 20/min, and blood pressure 100/60 mm Hg. The patient is in no distress. Physical examination discloses lumbar paraspinal spasm and crepitus of both knees. Fluid resuscitation was initiated in the emergency department. An image obtained during endoscopy is shown.

Which of the following is the most significant risk factor for development of this patient’s condition?

A) Alcohol consumption
B) Chemical exposure
C) Occupation
D) Travel to Mexico
E) Use of ibuprofen