A 39-year-old man presents to the emergency department after several episodes of hematemesis. Earlier in the evening, he attended a party and consumed a large amount of alcohol. He reports repeated forceful vomiting before noticing streaks of bright red blood in his vomitus. His medical history is otherwise unremarkable, and he does not take any medications. Temperature is 36.7°C (98.1°F), blood pressure is 124/74 mm Hg, pulse is 96/min, and respiratory rate is 16/min. Physical examination reveals mild epigastric tenderness to palpation. Laboratory studies demonstrate a hemoglobin level of 13.5 g/dL.
Which of the following is the most likely diagnosis?
The correct answer is:
C: Mallory-Weiss tear.
A Mallory-Weiss tear is a mucosal laceration at the gastroesophageal junction that occurs after forceful retching or vomiting. Patients typically present with hematemesis following episodes of vomiting, often in the setting of alcohol use. Most cases resolve spontaneously or with supportive care.
Answer choice A: Boerhaave syndrome, is incorrect.
Students often confuse these conditions because both follow vomiting. Boerhaave syndrome involves full-thickness esophageal rupture and typically presents with severe chest pain, systemic toxicity, and mediastinal complications.
Answer choice B: Esophageal adenocarcinoma, is incorrect.
Esophageal cancer generally causes progressive dysphagia and weight loss rather than acute hematemesis after vomiting.
Answer choice D: Peptic ulcer disease, is incorrect.
Peptic ulcers can cause upper GI bleeding but are not characteristically preceded by forceful retching.
Answer choice E: Variceal hemorrhage, is incorrect.
Variceal bleeding typically occurs in patients with portal hypertension and chronic liver disease.
Key Learning Point
Mallory-Weiss tears cause hematemesis following forceful vomiting and are usually limited to mucosal injury.
