Snapshot A 53-year-old man with a history of gastroesophageal reflux and alcohol abuse is brought to the emergency room by his family due to acute chest and back pain. He endorses alcohol use throughout the day and has been feeling very nauseated with emesis throughout the night. On evaluation, his blood pressure is 105/72 mmHg and pulse is 92/min. He had 1 episode of emesis with bright red blood in the room. Introduction Clinical definition longitudinal mucosal tear at the gastroesophageal junction or gastric cardia Epidemiology Up to 15% of all upper gastrointestinal bleeding Demographics middle age higher incidence in men Risk factors alcoholism hiatal hernia eating disorder food poisoning ETIOLOGY Pathogenesis rapid increase in intraabdominal pressure most commonly from forceful and repeated emesis straining coughing blunt abdominal trauma Presentation Symptoms hematemesis ranging from streaks to bright red blood melena or hematochezia epigastric pain back pain dizziness Physical exam tachycardia or hypotension guaiac positive stool Studies Diagnostic testing studies esophagogastroduodenoscopy visualizes tear and is diagnostic Differential Reflux esophagitis distinguishing factor irregularly shaped ulcerations Boerhaave syndrome distinguishing factor transmural esophageal tear Treatment Management approach initiate resuscitative measures to stabilize fluid resuscitation and blood replacement for hemodynamic support prompt diagnostic and therapeutic endoscopy for definitive treatment manage precipitating and exacerbating factors proton pump inhibitors sufficient as monotherapy for tears that are not actively bleeding antiemetics monitor for complications electrocardiogram and cardiac enzymes for secondary myocardial ischemia coagulation studies and complete blood count for coagulopathy and thrombocytopenia First-line endoscopic treatment indicated for active bleeding only (90% are self-limited) combined with epinephrine or sclerosant injection, thermal coagulation, banding, or hemoclips Second-line angiotherapy indicated for failed endoscopic management often with left gastric artery embolization Third-line surgery indicated for failed endoscopic management and angiotherapy, rarely used oversew mucosal tear Complications Rebleed Myocardial ischemia or infarction Hypovolemic shock Death