Mallory-Weiss Tear
The most likely diagnosis in this patient is a Mallory-Weiss tear, given the classic presentation of heavy alcohol consumption followed by prolonged vomiting and subsequent blood-tinged hematemesis in a patient with no prior medical history. 1, 2
Clinical Reasoning
Why Mallory-Weiss Tear is Most Likely
Mallory-Weiss tears are mucosal lacerations at or near the esophagogastric junction most commonly associated with vomiting, accounting for approximately 14-15.5% of all upper gastrointestinal bleeding cases 1, 2
The classic presentation involves forceful vomiting or retching that creates elevated esophageal pressure, leading to longitudinal mucosal tears 1, 3
Blood typically appears with the first episode of vomiting or shortly after repeated vomiting episodes, which matches this patient's presentation of blood-tinged vomitus after vomiting all morning 1
Alcohol consumption is the most common precipitating factor, as these tears are encountered most commonly in alcoholics attributed to episodes of excessive vomiting 1, 4
The bleeding is typically not massive - in one series, 37% of patients required no blood transfusions, consistent with this patient's unremarkable vital signs 1
Why Other Diagnoses are Less Likely
Boerhaave Syndrome:
- This represents full-thickness esophageal rupture (not just mucosal tear) and presents with severe chest pain, dyspnea, and often shock 3
- Patients typically appear critically ill with mediastinitis, not hemodynamically stable 3
- While both conditions share similar precipitating factors (alcohol, vomiting), Boerhaave syndrome is a surgical emergency with dramatically different clinical severity 3
Esophageal Varices:
- Requires underlying portal hypertension from cirrhosis or chronic liver disease 5
- This patient has no medical history, making varices extremely unlikely 6, 5
- Variceal bleeding typically presents with more massive hemorrhage and hemodynamic instability 5
Peptic Ulcer Disease:
- While peptic ulcers are the most common overall cause of nonvariceal upper GI bleeding, they are typically associated with chronic NSAID use, Helicobacter pylori infection, or other risk factors 7
- The temporal relationship between acute vomiting and bleeding onset strongly favors a mechanical tear rather than ulcer disease 1
- Peptic ulcers don't typically present immediately after an episode of prolonged vomiting 7
Important Clinical Caveats
Approximately 41% of patients with Mallory-Weiss tears have no antecedent nausea, retching, or vomiting, so the absence of these symptoms doesn't exclude the diagnosis 2
In 35% of cases, an additional potential bleeding site may be identified on endoscopy, so finding a Mallory-Weiss tear doesn't automatically mean it's the only lesion present 1
Most Mallory-Weiss tears stop bleeding spontaneously and require only supportive treatment, though 30% may need endoscopic therapy if bleeding continues 1, 2
Esophagogastroduodenoscopy remains the diagnostic gold standard and should be performed to confirm the diagnosis and provide therapeutic intervention if needed 6, 5