History and exam
Key diagnostic factors
common
presence of risk factors
Risk of MWT is most strongly associated with conditions predisposing to retching, vomiting, and/or straining (e.g., food poisoning, gastroenteritis, or any gastrointestinal condition resulting in obstruction; hepatitis, gallstones, cholecystitis, etc.), heavy alcohol use, chronic cough, and hiatal hernia. Mucosal tear or laceration during a routine endoscopy, although rare, is the most common cause of iatrogenic MWT.
haematemesis
Suspect acute upper gastrointestinal bleeding in any patient presenting with haematemesis. Most patients with MWT present with small and self-limiting episodes of haematemesis after a bout of retching, vomiting, coughing, straining, or blunt trauma, or any other factors that increase pressure at the level of the gastro-oesophageal junction. Haematemeis may vary, from flecks or streaks of blood mixed with gastric contents and/or mucus, blackish or 'coffee grounds', to a bright-red bloody emesis.
Although blood loss may be considerable in some patients, bleeding is self-limiting in 80% to 90% of patients.[2] Massive haemorrhage requiring blood transfusion and leading to death has been described, but it is extremely rare in MWT.[4][5][6]
Practical tip
Note that 'coffee ground' vomit is subjective. Perform a rectal examination to look for blood or signs of melaena, and calculate the Glasgow-Blatchford score (GBS). If GBS ≤1, consider managing the patient as an outpatient if safe and appropriate to do so.[31][32] See Risk stratification under Diagnosis recommendations.
Other diagnostic factors
common
light-headedness/dizziness
Can be due to a sudden drop in blood pressure caused by bleeding.
postural/orthostatic hypotension
Seen in up to 45% of adults with MWT.[13]
uncommon
dysphagia
Particularly in patients aged over 50 years with a new onset of dysphagia, in patients who smoke and drink alcohol on a regular basis, in patients with a long history of oesophageal reflux, and when it is progressive (for solid food first, then solid and liquids) in a short period of time (weeks or month).
odynophagia
Pain on swallowing food and fluids (odynophagia) is possible in MWT due to tear or laceration of the oesophagus.
retrosternal, epigastric, or back pain
Patients with MWT may experience retrosternal, epigastric, or back pain. However, severe pain is unusual in patients with MWT. If the patient describes severe pain, consider whether this might be caused by a deeper tear than the mucous membrane; investigate accordingly. A deeper tear may indicate an intramucosal oesophageal haematoma or transmural oesophageal rupture. Suspect an oesophageal perforation if the patient has retrosternal or epigastric pain alongside interscapular radiation, dyspnoea, cyanosis, and fever.
melaena
Perform a rectal examination in the patient with suspected upper gastrointestinal bleeding to look for signs of melaena.
haematochezia
Although blood loss may be considerable in some patients with MWT, bleeding is self-limiting in 80% to 90% of patients and haematochezia is rare.[2]
Haematochezia in MWT may occur if there is an actively bleeding lesion in which the rapidity of transit precludes any digestion of blood. Therefore, an unstable patient with haematochezia and other historical factors suggesting upper gastrointestinal bleeding requires urgent diagnosis and treatment.
shock
In most patients, hypovolaemic shock is secondary to rapid blood loss. Haemorrhage in MWT is self-limiting in 80% to 90% of patients.[2] Therefore, shock is rarely seen in patients with MWT.
Suspect a more serious underlying pathology, such as oesophageal varices, Dieulafoy's lesion, actively bleeding peptic ulcer disease, or aortoenteric fistula in patients with acute upper gastrointestinal bleeding and shock. See the Differentials section.
signs of anaemia
Rare in acute MWT.
Low haemoglobin at presentation may be indicative of co-existing comorbidities. Signs of anaemia include pallor, tachycardia, dyspnoea, and fatigue.
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