WBR0809

Author	[[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Serge Korjian)]]
Exam Type	USMLE Step 1
Main Category	Pathology
Sub Category	Gastrointestinal
Prompt	A 42-year-old patient presents to the emergency department with painful episodes bright red blood-tinged vomiting. Upon questioning, the patient denies any past medical or surgical history, intake of any medications, or any allergies. He explains that his symptoms began after an initial episode of violent retching he attributed to recent binge drinking. The patient's vital signs are stable and his physical examination is unremarkable. Following initial work-up, the patient undergoes endoscopy. Which of the following best characterizes the pathological process responsible for this patient's hematemesis?
Answer A	Transmural rupture of the esophagus wall.
Answer A Explanation	Boerhaave syndrome is characterized by the transmural rupture of the esophagus wall. Boerhaave syndrome is considered an emergency with a high mortality rate.
Answer B	Basal cell hyperplasia, papillary elongation, and inflammatory cell infiltrate in the distal esophagus
Answer B Explanation	Gastroesophageal reflux disease (GERD) is characterized by basal cell hyperplasia, papillary elongation, and inflammatory cell infiltrate in the distal esophagus.
Answer C	Increase in portal blood flow with venous congestion at the level of the esophagus
Answer C Explanation	Variceal bleeding is caused by portal hypertension commonly due to advanced liver disease. It is characterized by an increase in portal blood flow with venous congestion that eventually causes painless upper GI bleeding.
Answer D	Longitudinal mucosal lacerations in the gastric cardia
Answer D Explanation	Mallory-Weiss syndrome is characterized by the longitudinal mucosal lacerations in the gastric cardia.
Answer E	Pseudohyphae and budding spores in the esophageal squamous debris
Answer E Explanation	Candida esophagitis is characterized by pseudohyphae and budding spores in the esophageal squamous debris.
Right Answer	D
Explanation	Mallory-Weiss syndrome (MWS) is a frequent cause of hematemesis. It is characterized by upper GI bleeding due to the longitudinal mucosal laceration of the distal part of the esophagus or the proximal part of the stomach, the gastric cardia, that causes hematemesis following a submucosal arterial bleed. MWS is commonly caused by violent vomiting and retching in alcoholics and bulimics that cause an increase in intra-abdominal pressure, which is strong enough to cause the gastric cardia to protrude into the thoracic cavity through the hiatus and cause a longitudinal laceration. MWS tear accounts for approximately 15% of all cases of upper GI bleeding. Blood is classically arterial in origin and is bright red. The presentation of patients can vary from one episode of hematemesis to hypotension and progressive shock. depending on the extent of bleeding. Initial management is supportive as the majority of these tears resolve without intervention. Endoscopic ligation is reserved for patients with prolonged bleeding. Educational Objective: Mallory-Weiss syndrome (WMS) is characterized by the longitudinal laceration in the distal esophagus or the gastric cardia. It is a common cause of hematemesis in alcoholics and bulimics. References: Morales P, Baum A. Therapeutic alternatives for the Mallory-Weiss tear. Curr Treat Options Gastroenterol. 2003;6(1):75-83.
Approved	Yes
Keyword	Mallory-Weiss syndrome, WMS, Mallory-Weiss tear, Transmural tear, Laceration, Hematemesis, Endoscopy, Esophagus, Vomiting, Bulemia, Alcoholism, Alcoholic
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