Coffee Grounds

A 40 year old man with peptic ulcer disease, arthritis, and chronic low back pain presents with coffee ground emesis that began several hours ago. He takes only naproxen for his joint pain. He has a mild smoking and drinking history. His vital signs are: T 37.8, HR 95, BP 120/60, RR 14, SpO2 97%. His abdomen is diffusely tender.

You place a nasogastric tube and do an NG lavage but no blood or coffee grounds comes back. Instead, the patient becomes acutely agitated, tachypneic, and hypoxic. Vital signs are T 37.6, HR 110, BP 130/70, RR 20, SpO2 90%. You get a chest X-ray, shown below.

Challenge: What happened?

Image shown under Fair Use.