A 24-year-old, previously healthy woman comes to the emergency department due to hematemesis. The patient was binge drinking when she became very nauseated and began vomiting repeatedly. She reports vomiting approximately a cupful of bright red blood during the most recent episode. Blood pressure is 136/78 mm Hg and pulse is 96/min. Physical examination shows mild epigastric tenderness. Endoscopy reveals a longitudinal mucosal laceration in the distal esophagus with active bleeding. Endoscopic treatment is performed, but the bleeding recurs. Angiography with transarterial embolization of the bleeding vessel is planned. A distal branch of which of the following blood vessels is most likely to be embolized during this patient's procedure?

Question

A 24-year-old, previously healthy woman comes to the emergency department due to hematemesis.  The patient was binge drinking when she became very nauseated and began vomiting repeatedly.  She reports vomiting approximately a cupful of bright red blood during the most recent episode.  Blood pressure is 136/78 mm Hg and pulse is 96/min.  Physical examination shows mild epigastric tenderness.  Endoscopy reveals a longitudinal mucosal laceration in the distal esophagus with active bleeding.  Endoscopic treatment is performed, but the bleeding recurs.  Angiography with transarterial embolization of the bleeding vessel is planned.  A distal branch of which of the following blood vessels is most likely to be embolized during this patient's procedure?

Quizplus · Accepted Answer

11ec160b_3580_892c_9249_d74176b1e4e1_MD0001_00 This patient has a mucosal laceration of the distal esophagus (Mallory-Weiss tear). It typically occurs during episodes of severe retching, which can raise intraabdominal pressure high enough to tear the superficial layers of the distal esophagus. Mallory-Weiss tears cause hematemesis, which is often self-limited, although severe bleeding may require endoscopy and/or angiography. Arterial embolization in this patient should target branches of the left gastric artery, which arises from the celiac trunk and provides the primary arterial supply to the distal esophagus. Branches of the left inferior phrenic artery may also perfuse the distal esophagus but are a minor contributor. More proximal segments of the esophagus are served by other primary arteries. The proximal esophagus receives arterial blood from branches of the inferior thyroid artery, whereas the midesophagus is supplied by branches of the thoracic aorta. (Choice A) The internal thoracic artery (internal mammary artery) is derived from the subclavian artery and travels just deep to the anterior chest wall. Its terminal branches are the musculophrenic artery and the superior epigastric artery. The internal thoracic artery supplies the anterior chest wall and breasts but does not supply the esophagus. (Choice C) In addition to the left gastric artery, the other major branches of the celiac trunk include the common hepatic and splenic arteries. The splenic artery is a tortuous vessel that runs posterior to the stomach and supplies the spleen but does not perfuse the esophagus. (Choice D) The superior mesenteric artery branches directly from the abdominal aorta and provides arterial supply to the duodenum, small intestines, and proximal two-thirds of the colon (up to the splenic flexure). It does not supply the esophagus. (Choice E) The midesophagus receives arterial blood from branches of the thoracic aorta; this patient's tear involves the distal esophagus, so these branches would not require embolization. Educational objective: Forceful retching can lead to superficial mucosal lacerations (eg, Mallory-Weiss tears) of the distal esophagus, an area that receives most of its arterial blood supply from branches of the left gastric artery. The proximal esophagus receives arterial blood from the inferior thyroid artery, whereas the midesophagus is supplied by branches of the thoracic aorta.

A 24-Year-Old, Previously Healthy Woman Comes to the Emergency Department