life-threatening mallory-weiss tears: from upper gastrointestinal bleed to multisystem crisis - a case report

Introduction: hypoxic respiratory failure, defined as arterial oxygen tension (pao₂) <60 mmhg on room air,is commonly caused by pulmonary conditions such as pneumonia, pulmonary embolism, or acute respiratorydistress syndrome. less frequently, systemic factors such as hemorrhagic shock can impair oxygen deliverydue to severe anemia and reduced perfusion. mallory-weiss tears (mwts) are longitudinal mucosal lacerationsat the gastroesophageal junction, typically caused by vomiting or retching, and may result in significant uppergastrointestinal (gi) bleeding.case description: we report a case of an 81-year-old woman with gastroesophageal reflux disease and a priorcerebral infarct for which she was taking apixaban. she presented with stroke-like symptoms and becamehypoxic en route to the hospital, requiring intubation. laboratory evaluation revealed profound anemia(hemoglobin 2.8 g/dl), metabolic acidosis (ph 6.95, bicarbonate 8 mmol/l), and elevated lactic acid (8.1 mg/dl). she received multiple blood products, reversal of anticoagulation, and supportive care in the intensive careunit. initial imaging showed a hiatal hernia but no active bleeding. nasogastric output demonstrated coffeeground material. esophagogastroduodenoscopy on day 2 revealed an mwt. she was extubated on day 3 anddischarged on day 11.discussion: this case emphasizes the importance of considering non-pulmonary causes of hypoxia, particularlysevere anemia from occult gi bleeding, even in the absence of overt signs. hypoxia was primarily drivenby reduced oxygen-carrying capacity rather than intrinsic lung pathology. timely recognition, endoscopicdiagnosis, hemostasis, and restoration of hemoglobin reversed respiratory compromise. clinicians shouldmaintain a high index of suspicion for occult bleeding in unexplained hypoxic respiratory failure.