History and exam

Key diagnostic factors

common

hematemesis

The classic presentation of MWT consists of a small and self-limited episode of hematemesis (flecks or streaks of blood mixed with gastric contents and/or mucus, blackish or "coffee grounds") after a bout of retching, vomiting, coughing, straining, blunt trauma, or any other factors that increase pressure at the level of the gastroesophageal junction.[1] ​Patients may also present with a frank bright-red bloody emesis. 

However, this classic presentation occurs in only 29% of patients.[55] Another study reported blood on the first emesis in only 50% of patients.[14] A high index of suspicion is imperative in these circumstances. Massive hemorrhage requiring blood transfusion and even leading to death has been described, but it is extremely rare in MWT.[3][4]​​[55]​​​

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.[14]

uncommon

dysphagia

Considered an alarming symptom in patients over the age of 50 with a new onset of dysphagia, in those who smoke and drink alcohol on a regular basis, in those with a long history of esophageal reflux and when it is progressive (for solid food first, then solid and liquids) in a short period of time (weeks or month). These patients need an immediate evaluation to determine the exact cause (which may be an upper gastrointestinal neoplasm) and to initiate appropriate therapy.

odynophagia

Pain on swallowing food and fluids (odynophagia) is possible in MWT due to tear or laceration of the esophagus.

pain

Degree, location (retrosternal, epigastric, or back pain), and character of the pain should be obtained from the patient. Hematemesis in MWT is sometimes accompanied by pain.

The main differential diagnosis in this group of patients is with Boerhaave syndrome (spontaneous rupture of the esophagus), which may have a similar presentation.

melena

Usually associated with upper gastrointestinal bleeding proximal to the ligament of Treitz. Confounding factors for melena include bismuth-containing products (e.g., Pepto-Bismol) and iron supplements.

hematochezia

Hematochezia is rare.

Hematochezia in MWT can be seen in an actively bleeding lesion in which the rapidity of the transit precludes any digestion of blood. Therefore, an unstable patient with hematochezia and other factors suggesting upper gastrointestinal bleeding requires urgent diagnosis and treatment.

shock

In most patients, hypovolemic shock is secondary to rapid blood loss. Shock in MWT is rare.[1]

Shock may suggest more serious underlying pathology such as esophageal varices, Dieulafoy lesion, actively bleeding peptic ulcer disease, or aortoenteric fistula.

signs of anemia

Rare in acute MWT.

Low Hb at presentation may indicate coexisting comorbidities. Signs of anemia include pallor, tachycardia, dyspnea, and fatigue.

Risk factors

strong

condition predisposing to retching, vomiting, and/or straining

Conditions that may induce vomiting include: food poisoning, gastroenteritis, or any gastrointestinal condition resulting in obstruction; hepatitis, gallstones, and cholecystitis; hyperemesis gravidarum; urinary tract infection, renal failure, and ureteropelvic obstruction; brain tumors, hydrocephalus, congenital disease, trauma, meningitis, pseudotumor cerebri, migraine headaches, and seizures; anorexia nervosa, bulimia, and cyclic vomiting syndrome.[12][17]​​[18][19] Toxins, polyethylene glycol lavage, chemotherapy agents, and postanesthesia or postsurgery are also causes.[20][21][22]

chronic cough

May be associated with whooping cough, bronchitis, bronchiectasis, emphysema, COPD, or lung cancer.[23]

hiatus hernia

Hiatus hernia has been found to be present in 40% to 100% of patients with MWT and it is considered to be a precipitating factor.[4][15][16]

retching during endoscopy or other instrumentation

Mucosal tear or laceration during a routine endoscopy is a rare event (0.0001% to 0.4% of cases).[24][25] However, it is considered to be the most common cause of iatrogenic tear or laceration.​

Other procedures involving instrumentation that may be associated with esophageal tear or laceration include nasogastric or orogastric tube placement, endoscope band ligation, endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound.[26]

significant alcohol use

History of significant alcohol use and vomiting is common in patients who present with MWT. Alcohol has a reported association in 40% to 80% of patients.[11][16][27]

previous instrumentation

Iatrogenic MWTs are rare and generally have a benign course. They tend to occur mostly in patients who have experienced excessive retching, struggling during endoscopy, longer endoscope time, and excessive air inflow. It tends to occur in patients who are female, elderly, and those with hiatus hernias.[28][29]

weak

age 30 to 50 years

Most patients are between 30 and 50 years of age, although it has been reported in infants as young as 3 weeks old, as well as in older people.[10][24][30]

male sex

More common in men than women in a ratio of 3:1.[11]

use of aspirin or other nonsteroidal anti-inflammatory drugs

Ingestion of aspirin or other nonsteroidal anti-inflammatory drugs has been associated with MWT.[31][32]

hiccups

Hiccups have been associated with MWT.[33][34]

blunt abdominal trauma

A sudden increase of intraluminal pressure against a closed glottis has been suggested as the main mechanism for development of MWT, although the pathogenesis is uncertain.[35] Blunt abdominal trauma is one of the mechanisms by which intraluminal pressure can increase.

cardiopulmonary resuscitation

Exact pathogenesis is uncertain, although compression of the esophagus between the sternum and the vertebrae is probably the most likely explanation.[36]

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