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For further information, see CMDT Part 15-19: Benign Esophageal Lesions

Key Features

Essentials of Diagnosis

  • Hematemesis; usually self-limited

  • Prior history of vomiting, retching in 50%

  • Endoscopy establishes diagnosis

General Considerations

  • Characterized by a nonpenetrating mucosal tear at the gastroesophageal junction

  • Events that suddenly raise transabdominal pressure, such as lifting, retching, or vomiting, may be contributory

  • Alcohol use disorder is a strong predisposing factor

  • Accounts for ~5% of upper gastrointestinal bleeding

Clinical Findings

Symptoms and Signs

  • History of vomiting, retching, straining in 50%

  • Hematemesis with or without melena

Differential Diagnosis


  • Hemoptysis

  • Erosive esophagitis

  • Peptic ulcer disease

  • Esophageal or gastric varices

  • Erosive gastritis, eg, nonsteroidal anti-inflammatory drugs, alcohol, stress

  • Portal hypertensive gastropathy

  • Vascular ectasias (angiodysplasias)

  • Gastric cancer


  • Aortoenteric fistula

  • Dieulafoy lesion (aberrant gastric submucosal artery)

  • Hemobilia (blood in biliary tree), eg, iatrogenic, malignancy

  • Pancreatic cancer

  • Hemosuccus pancreaticus (pancreatic pseudoaneurysm)


Laboratory Tests

  • Complete blood count

  • Platelet count

  • Prothrombin time

  • Partial thromboplastin time

  • Serum creatinine

  • Liver enzymes and serologies

  • Type and cross-matching for 2–4 units or more of packed red blood cells

  • Hematocrit is not a reliable indicator of the severity of acute bleeding

Diagnostic Procedures

  • Upper endoscopy

    • Diagnostic

    • Identifies a 0.5–4.0 cm linear mucosal tear usually located either at the gastroesophageal junction or, more commonly, just below the junction in the gastric mucosa



  • Angiographic arterial embolization or operative intervention is required in patients in whom endoscopic therapy fails

Therapeutic Procedures

  • Patients are initially treated as needed with fluid resuscitation and blood transfusions

  • Most patients stop bleeding spontaneously and require no therapy

  • Endoscopic hemostatic therapy is used in patients who have continuing active bleeding

  • Injection with epinephrine (1:10,000), cautery with a bipolar or heater probe coagulation device, or mechanical compression of the artery by application of an endoclip or band is effective in 90–95% of cases



  • None required


  • Persistent bleeding


  • Most Mallory-Weiss bleeds stop spontaneously with rapid healing of mucosal tears

  • Persistent or recurrent bleeding most likely in patients with concomitant portal hypertension or coagulopathy

When to Admit

  • All patients with significant hematemesis


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