Snapshot A 75 year old male presents to the emergency room with 2 hours of bloody emesis. He states that yesterday evening he was intoxicated and can't remember what happened. He awoke this morning with severe nausea and emesis. Vital signs are within normal limits at this time. Introduction Longitudinal tears in proximal stomach or distal esophageal Occur after retching seen in alcoholics, bulimics Cause of upper GI bleeds Tear is through the mucosal layer but not through the full muscular layer, differentiate with Boerhaave's syndrome Presentation Hematemesis coffee ground appearance or bright red blood Vital signs may be altered depending on severity of the bleed Found in patients with episodes of vomiting or wretching, ie alcoholis, bulimics Diagnosis Chest XRay may show small flecks of air in the mediastinum CT scan of the chest may show small flecks of air in the mediastinum Endoscopy is gold standard for diagnosis to directly assess the quality of the esophagus Barium swallow should not display a full thickness tear. Treatment Patient must first be stabilized from a hemodynamic perspective Interventional radiology may be required to embolize bleeding vessel Endoscopy can be used to cauterize of clip the bleeding area Antiacid medications are used to decrease the acid burden in the esophagus