A 20-year-old woman comes to the emergency department complaining of nausea and vomiting. She awoke that morning with the sudden onset of nausea and vomiting. She vomited about 10 times and became concerned when she noticed blood in the vomitus. The patient has no dysphagia or odynophagia. Her other medical problems include a history of menorrhagia and bulimia. She takes naproxen daily for chronic low back pain and does not use tobacco, alcohol, or illicit drugs.
Her blood pressure is 109/60 mm Hg, pulse is 106/min, and respirations are 14/min. Examination shows dry mucous membranes. The abdomen is soft and nontender. There is no hepatomegaly or splenomegaly.
Laboratory results are as follows:

Test for stool occult blood is negative.
Which of the following is the most appropriate next step in management?

Question

A 20-year-old woman comes to the emergency department complaining of nausea and vomiting.  She awoke that morning with the sudden onset of nausea and vomiting.  She vomited about 10 times and became concerned when she noticed blood in the vomitus.  The patient has no dysphagia or odynophagia.  Her other medical problems include a history of menorrhagia and bulimia.  She takes naproxen daily for chronic low back pain and does not use tobacco, alcohol, or illicit drugs.
Her blood pressure is 109/60 mm Hg, pulse is 106/min, and respirations are 14/min.  Examination shows dry mucous membranes.  The abdomen is soft and nontender.  There is no hepatomegaly or splenomegaly.
Laboratory results are as follows:

Test for stool occult blood is negative.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

This patient's presentation suggests Mallory-Weiss (MW) tear. MW tear is an upper gastrointestinal mucosal tear due to a sudden increase of intra-abdominal pressure from forceful retching. This can lead to submucosal arterial or venule plexus bleeding. Bleeding is self-limited (24-48 hours) in most patients. However, life-threatening bleeding can occur. Patients typically present with epigastric pain radiating to the back and hematemesis after extended nausea and vomiting. Esophagogastroduodenoscopy (EGD) is preferred for diagnosis and differentiating MW tear from esophagitis due to other conditions (eg, reflux, infectious, pill-induced). MW tears are usually located near the distal esophagus and proximal stomach. Most physicians also use proton pump inhibitors even though the benefit in MW tears is not clear. (Choice A) Angiographic arterial embolization is rarely required in patients with refractory bleeding. (Choice B) Barium swallow is indicated for patients with dysphagia (eg, Schatzki rings or motility disorders). It would not be able to properly identify a MW tear. (Choice D) Based on data from observational studies, most urgent endoscopic procedures can be performed safely if the INR is < 1.5-2.5. Endoscopic therapy in these patients has similar success rate and rebleeding risk as non-anticoagulated patients. (Choice E) Intravenous octreotide is commonly used in the management of variceal bleeding due to its ability to reduce splanchnic blood flow. It has no role in the treatment of MW tears. Educational objective: Mallory-Weiss tear is an upper gastrointestinal mucosal tear due to a sudden increase of intra-abdominal pressure from forceful retching. Endoscopy is preferred for diagnosis. Most patients have self-limited (24-48 hours) bleeding with spontaneous healing of ulcers. Patients with active bleeding usually require endoscopic treatment with epinephrine injection, cautery, or hemoclip application. __________ References: Mallory-Weiss tear: predisposing factors and predictors of a complicated course. (http://www.ncbi.nlm.nih.gov/pubmed/11693318) Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. (http://www.ncbi.nlm.nih.gov/pubmed/19091393) Impact of anticoagulation on rebleeding following endoscopic therapy for nonvariceal upper gastrointestinal hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/17100959)

A 20-Year-Old Woman Comes to the Emergency Department Complaining of Nausea