Snapshot A 21-year-old male presents to the emergency department with hematemesis. He had been out drinking every night that week with his friends in celebration of his 21st birthday. He reports having vomited each night, but tonight when he started vomiting, his friends noticed that there was streaking of blood and brought him into the emergency department. Introduction Superficial longitudinal mucosal lacerations of the distal esophagus or proximal stomach Associated with forceful retching, alcoholism, and hiatal hernias Amount of blood loss is usually small and self-limited Accounts for approximately 5% of all presentations of upper GI bleeds Presentation Symptoms blood in vomit blood in stool dark stools epigastric pain back pain Physical exam upper GI bleed hemodynamic instability can occur with large bleeds signs include hypotension/tachycardia Evaluation Mallory-Weiss tears are diagnosed via direct visualization under endoscopy Differential Esophageal varices, Boerhaave's syndrome, ulcerative diseases of the esophagus (including reflux esophagitis or infectious esophagitis) Treatment Medical management supportive therapy and observation management of hemodynamic instability including IV fluids blood transfusion if needed most bleeds resolve spontaneously Surgical/procedural intervention upper endoscopy first-line treatment for persistent bleeds combined with epinephrine or sclerosant injection, thermal coagulation, banding, or hemoclips to control bleeding angiotherapy often with left gastric artery embolization performed by interventional radiology indicated in cases refractory to endoscopic treatment surgical repair oversowing of the mucosal tear is rarely indicated even in refractory cases Prognosis, Prevention, and Complications Prognosis bleeding stops spontaneously in 80-90% of patients up to 10% of patients will experience hemodynamic instability recurrence of Mallory-Weiss tears is rare Prevention avoid engaging in activities that lead to excessive coughing or vomiting (i.e. binge drinking) Complications hypovolemic shock, organ infarction, and death are possible if bleeding is not controlled