Gastroenterology · Upper Gastrointestinal Bleeding
The facts most likely to be tested
Mallory-Weiss tears are longitudinal mucosal lacerations located at the gastroesophageal junction or gastric cardia.
The classic clinical presentation is hematemesis following a history of forceful retching, vomiting, or alcohol use.
The primary pathophysiology involves a sudden increase in transabdominal pressure leading to a tear in the esophageal mucosa.
Upper endoscopy (EGD) is the diagnostic test of choice to visualize the tear and rule out other causes of upper GI bleeding.
Most Mallory-Weiss tears are self-limiting and resolve spontaneously with supportive care and fluid resuscitation.
Endoscopic intervention, such as epinephrine injection, cautery, or hemostatic clips, is reserved for patients with active bleeding or hemodynamic instability.
Mallory-Weiss tears are distinguished from Boerhaave syndrome by the absence of esophageal perforation, mediastinitis, and subcutaneous emphysema.
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A 45-year-old male presents to the emergency department with two episodes of bright red hematemesis. He reports a history of heavy alcohol consumption and states that the bleeding began after several hours of forceful, repetitive vomiting following a party. On physical examination, his blood pressure is 118/76 mmHg and his heart rate is 88 bpm. He has no signs of peritoneal irritation, and his lungs are clear to auscultation. An upper endoscopy is performed, revealing a longitudinal mucosal tear at the gastroesophageal junction.
What is the most likely diagnosis?
Mallory-Weiss tear
The patient's history of forceful vomiting followed by hematemesis is classic for a Mallory-Weiss tear, which is confirmed by the endoscopic finding of a longitudinal mucosal tear at the gastroesophageal junction.
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Etiology / Epidemiology
Caused by forceful retching or vomiting; highly associated with alcohol use disorder and bulimia.
Clinical Manifestations
Presents as hematemesis following a period of non-bloody emesis; classic post-emetic history.
Diagnosis
Upper endoscopy (EGD) is the gold standard; reveals a longitudinal mucosal tear at the GE junction.
Treatment
Most cases are self-limiting; use endoscopic hemostasis (clips/cautery) for active bleeding; avoid NSAIDs.
Prognosis
Excellent; 90% of cases resolve spontaneously; monitor for hypovolemic shock.
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Epidemiology & Etiology
Common in patients with alcohol use disorder due to frequent retching. Also seen in patients with bulimia nervosa or hyperemesis gravidarum. Increased intra-abdominal pressure is the primary trigger.
Pertinent Anatomy
The tear occurs at the gastroesophageal junction or proximal gastric cardia. These are typically longitudinal tears rather than circumferential.
Pathophysiology
Sudden increase in transgastric pressure during retching or vomiting causes a mechanical tear of the mucosa. The tear involves the mucosa and submucosa but typically spares the muscularis propria. This distinguishes it from the transmural rupture seen in Boerhaave syndrome.
Clinical Manifestations
Patients report an initial episode of non-bloody vomiting followed by hematemesis. The post-emetic nature is the classic board buzzword. Red flags include tachycardia, hypotension, or syncope indicating significant blood loss.
Diagnosis
Upper endoscopy (EGD) is the diagnostic test of choice. It identifies the longitudinal mucosal tear at the GE junction. Perform EGD once the patient is hemodynamically stable.
Treatment
Initial management focuses on fluid resuscitation. Most tears stop bleeding spontaneously. For active bleeding, endoscopic hemostasis (thermal coagulation, clips, or epinephrine injection) is the first-line intervention. Avoid NSAIDs as they increase the risk of re-bleeding.
Prognosis
Prognosis is excellent with 90% of cases resolving with supportive care alone. Recurrence is rare unless the underlying cause of vomiting persists. Monitor for signs of hypovolemic shock in the acute phase.
Differential Diagnosis
Boerhaave syndrome: presents with severe retrosternal chest pain and subcutaneous emphysema
Esophageal varices: associated with portal hypertension and cirrhosis
Peptic ulcer disease: usually presents with epigastric pain rather than post-emetic hematemesis
Gastritis: typically presents with burning pain rather than significant hematemesis
Dieulafoy lesion: a large, tortuous submucosal artery that causes painless, massive hemorrhage