ANSWER 84
The most likely diagnosis is a tear of the mucosa in the lower oesophagus or upper stom-
ach causing haematemesis (a Mallory–Weiss lesion). This is produced from the mechan-
ical trauma of violent vomiting or retching. In this case, it may have been triggered by an
unaccustomed large alcohol intake.
The estimation of blood loss is often difficult from the patient’s story. Haematemesis is a
frightening symptom and the amount may be overestimated. The haemoglobin level here
is normal and it is unlikely to be helpful in an acute bleed. If it were low at this stage it
would be more likely to imply chronic blood loss. The first signs of significant blood loss
would be likely to be tachycardia and a postural drop in blood pressure. His pulse is fast
but this may well be related to anxiety.
Other possible causes of haematemesis are gastritis or peptic ulcer. The story of retching and
vomiting of gastric contents with no blood on several occasions before the haematemesis is
characteristic of Mallory–Weiss syndrome. This is usually a benign condition which does not
need intervention. Definitive diagnosis requires upper gastrointestinal endoscopy but is not
always necessary in a typical case. Occasionally the blood loss is more substantial or the
split in the wall may be deeper than just the mucosa, leading to perforation.
Management in this case was with careful observation, intravenous fluid to replace lost
volume from vomiting. Blood was taken for blood grouping in case of more substantial
haemorrhage but transfusion was not necessary. He was treated with an anti-emetic and an
H 2 -blocker. The vomiting settled and there was no more bleeding. He decided to indulge
less at future parties.
- A history of violent retching or vomiting without blood before haematemesis suggests an
upper gastrointestinal mucosal tear. - It is difficult to be sure of the degree of blood loss in haematemesis because the patient
will find it difficult to quantitate the volume of blood, and the amount of blood still in
the gastrointestinal tract is unknown. - In some surveys alcohol is linked directly to around one-quarter of acute medical
admissions.