Gastrointestinal Bleeding Answers 309area of the mucosa or submucosa of the GI tract; 75% of cases occur in the
stomach with the remainder near the gastroesophageal (GE) junction. Bleeding
is usually mild and self-limited. However, 3% of deaths from upper GI bleeds
result from Mallory-Weiss tears.
(a)Esophageal varices are dilated submucosal veins found in 50% of
patients with cirrhosis of the liver. They usually develop as a result of portal
hypertension. Up to 30% of patients with esophageal varices develop upper GI
bleeds, and the bleeding is usually massive. Patients are often asymptomatic
until the varices rupture and bleed. Although this patient is certainly
predisposed to varices secondary to his ethanol abuse, his acute presentation
of pain after vomiting is more consistent with a Mallory-Weiss tear.
(b)Boerhaave syndrome involves a spontaneous full thickness perforation
of the esophagus—80% involving the posterolateral aspect of the distal
esophagus—that usually results from violent retching. Alcohol ingestion is
a risk factor. Because the overlying pleura is torn, esophageal contents can spill
into the mediastinum and thorax, leading to severe epigastric and retrosternal
chest pain, with radiations to the back, neck, or shoulders. Characteristic
findings on chest radiograph include a left pneumothorax, a left pleural
effusion, mediastinal emphysema, and a widened mediastinum, all of
which the individual in the question does not exhibit. Boerhaave syndrome
represents a surgical emergency, with mortality approaching 50% if surgery
is not performed within 24 hours. (c)A Curling ulcer is an ulcer or erosion
caused by stress gastritis because of patients with severe burn injuries. The
most common finding is painless GI bleeding. There is no evidence of severe
burn injury in this patient. (d)A perforated gastric ulcer is a complication
of chronic gastritis, which is usually associated with severe, acute abdominal
pain. Perforations occur when an ulcer erodes through the wall and leaks
air and digestive contents into the peritoneal cavity. Often, pain initially
begins in the epigastrium but becomes generalized shortly thereafter. Patients
usually lie still and avoid movement that might disturb the peritonealcavity.
An upright chest radiograph may demonstrate air under the diaphragm.
280.The answer is d.(Tintinalli, pp 504-505, 512-513.)Esophageal
varicesdevelop in patients with chronic liver diseasein response to portal
hypertension. Approximately 60% of patients with portal hypertension will
develop varices. Of those who develop varices, 25% to 30% will experience
hemorrhage. Patients who develop varices from alcohol abuse have an even
higher risk of bleeding, especially with ongoing alcohol consumption. This
patient has evidence of chronic liver disease with thrombocytopenia and