A 46-year-old man comes to the emergency department due to several episodes of vomiting. The last episode of emesis contained blood. Five hours ago, he had a fatty meal and several alcoholic drinks. The patient's medical history is notable for alcohol use disorder. He also has chronic dyspepsia, for which he was evaluated 3 days ago with upper gastrointestinal endoscopy and abdominal ultrasound. The ultrasound revealed an enlarged, hyperechoic liver and gallstones in the gallbladder, and the endoscopy found mild esophagitis and gastritis. His temperature is 36.6 C (97.9 F), blood pressure is 120/70 mm Hg, pulse is 95/min, and respirations are 15/min. The abdomen is soft and nontender. The rectal examination shows no melena. Laboratory results are as follows: Nasogastric suction returns normal stomach contents mixed with bright red blood. Which of the following is the most likely explanation for this patient's bloody vomiting?

Question

A 46-year-old man comes to the emergency department due to several episodes of vomiting.  The last episode of emesis contained blood.  Five hours ago, he had a fatty meal and several alcoholic drinks.  The patient's medical history is notable for alcohol use disorder.  He also has chronic dyspepsia, for which he was evaluated 3 days ago with upper gastrointestinal endoscopy and abdominal ultrasound.  The ultrasound revealed an enlarged, hyperechoic liver and gallstones in the gallbladder, and the endoscopy found mild esophagitis and gastritis.  His temperature is 36.6 C (97.9 F), blood pressure is 120/70 mm Hg, pulse is 95/min, and respirations are 15/min.  The abdomen is soft and nontender.  The rectal examination shows no melena.  Laboratory results are as follows:  Nasogastric suction returns normal stomach contents mixed with bright red blood.  Which of the following is the most likely explanation for this patient's bloody vomiting?

Quizplus · Accepted Answer

11ec25c8_d8fe_63c7_bc81_abb7a34c10b5_MD0003_00 This patient with alcohol use disorder, alcoholic hepatitis (2:1 ratio of aspartate aminotransferase to alanine aminotransferase), esophagitis, and gastritis now has acute, bright red hematemesis following multiple episodes of vomiting. This presentation is highly suggestive of a Mallory-Weiss tear (MWT). MWT is characterized by longitudinal tears in the mucosa near the gastroesophageal junction, with bleeding due to injury to the submucosal arteries or veins. It typically occurs due to a sudden increase in intraabdominal pressure (eg, retching, blunt abdominal trauma). MWT is a common cause of upper gastrointestinal (GI) hemorrhage and is often seen in association with alcohol use disorder and hiatal hernia. The diagnosis can be confirmed on endoscopy. Bleeding stops spontaneously in 90% of patients. Those with ongoing bleeding can be treated endoscopically with electrocoagulation or local injection of epinephrine. (Choices A and B) Esophageal rupture can be caused by severe retching (Boerhaave syndrome), penetrating trauma, or as a complication of endoscopy. It is characterized by acute chest pain, subcutaneous emphysema, and often a left-sided pleural effusion. When esophageal rupture occurs due to endoscopy, it is usually apparent shortly after the procedure. (Choice C) Hemobilia (bleeding in the biliary tree) is an uncommon cause of upper GI hemorrhage. It is typically seen following abdominal trauma or surgery. Endoscopy without manipulation of the biliary system would not cause hemobilia. (Choice E) Esophageal varices are submucosal veins that have dilated due to portal hypertension. Eventual rupture causes upper GI bleeding. However, varices would likely have been visible on this patient's endoscopy 3 days earlier. (Choice F) Stress ulcers develop in the setting of severe and prolonged physiological stress. GI bleeding from stress ulcers is usually seen in patients in an intensive care or burn unit setting. Educational objective: Mallory-Weiss tear occurs due to a sudden increase in intraabdominal pressure (eg, retching), leading to a mucosal tear and hematemesis. The diagnosis can be confirmed on endoscopy. Bleeding stops spontaneously in most patients, but those with ongoing bleeding can be treated endoscopically. References: Endoscopic management of Mallory-Weiss tearing. (http://www.ncbi.nlm.nih.gov/pubmed/25844336)

A 46-Year-Old Man Comes to the Emergency Department Due to Several