A 42-year-old male with a history of alcohol use disorder presents to the emergency department with hematemesis preceded by forceful vomiting after a heavy drinking session. Upper endoscopy is performed and reveals the lesion marked **A** in the diagram—linear longitudinal mucosal tears at the gastroesophageal junction. Which of the following best characterizes the pathophysiology of this lesion?
A. Dilated submucosal venous channels at the gastroesophageal junction prone to rupture
B. Full-thickness transmural perforation of the esophagus extending into the mediastinum
C. Non-penetrating mucosal/submucosal laceration caused by sudden increase in transmural pressure gradient during forceful vomiting
D. Acute mucosal erosion secondary to acid reflux and peptic injury at the gastroesophageal junction
Explanation
Why "Non-penetrating mucosal/submucosal laceration caused by sudden increase in transmural pressure gradient during forceful vomiting" is right
The structure marked A represents a Mallory-Weiss tear (MWT), which is defined as a non-penetrating longitudinal mucosal/submucosal laceration at the gastroesophageal junction. The pathophysiology is distinctly characterized by a sudden marked increase in transmural pressure gradient across the GEJ during forceful vomiting, retching, or Valsalva maneuver—not a full-thickness perforation. This mechanism explains why the lesion occurs in the setting of alcohol-induced vomiting and why it is self-limited in 80–90% of cases. (Harrison's 21e Ch 47; ASGE Guidelines Upper GI Bleeding 2023)
Why each distractor is wrong
Full-thickness transmural perforation of the esophagus extending into the mediastinum: This describes a Boerhaave perforation, not a Mallory-Weiss tear. Boerhaave is transmural and life-threatening; MWT is non-penetrating and usually self-limited. The clinical anchor explicitly distinguishes MWT from full-thickness perforation.
Dilated submucosal venous channels at the gastroesophageal junction prone to rupture: This describes esophageal varices (option C in the diagram), which are a different cause of upper GI bleeding. Varices are chronic vascular lesions, not acute mucosal tears from trauma.
Acute mucosal erosion secondary to acid reflux and peptic injury at the gastroesophageal junction: This describes peptic ulcer disease or reflux-induced erosions, not the mechanical laceration caused by pressure trauma during vomiting. MWT is a mechanical injury, not an acid-mediated process.
High-YieldNEET PG
Mallory-Weiss tear = non-penetrating mucosal tear at GEJ from sudden pressure surge during vomiting; Boerhaave = full-thickness perforation from same mechanism but more severe trauma.
Harrison's 21e Ch 47; ASGE Guidelines Upper GI Bleeding 2023
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