Mallory-Weiss Tear: The Daily PANCE Blueprint
A 34-year-old man comes to the emergency department after a weekend of heavy drinking. He describes several hours of forceful retching and non-bloody vomiting, and then, on the last few episodes, streaks of bright red blood in the vomitus. He is hemodynamically stable with a blood pressure of 124/78 and heart rate 88. His abdomen is soft, and he has no jaundice, no spider angiomata, and no ascites. Chest radiograph shows no free air or mediastinal widening. Which of the following is the most likely diagnosis?
A. Bleeding esophageal varices
B. Boerhaave syndrome
C. Peptic ulcer disease
D. Gastric adenocarcinoma
E. Mallory-Weiss tear
Answer and topic summary
The answer is E. Mallory-Weiss tear
Forceful retching first, then blood — that sequence is the signature of a Mallory-Weiss tear, a longitudinal mucosal laceration at the gastroesophageal junction caused by the sudden pressure spike of vomiting. The bleeding is usually self-limited, and roughly 90% stop without intervention; management is supportive, with endoscopy for ongoing bleeding. Two look-alikes matter. Boerhaave syndrome is the full-thickness rupture of the same mechanism, and it presents sick — severe chest pain, subcutaneous emphysema, mediastinal air on imaging — none of which he has. Esophageal varices would be the concern if he had stigmata of portal hypertension, but he has no jaundice, spider angiomata, or ascites, and varices classically bleed without a preceding retching history. Peptic ulcer disease usually brings epigastric pain or melena rather than this clean retch-then-blood story, and gastric cancer presents with weight loss and early satiety over months.
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Covered under ⇒ PANCE Blueprint Gastroenterology ⇒ ⇒
