Mallory-Weiss tear: Difference between revisions
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==Management== | ==Management== | ||
*Most Mallory-Weiss tears are minor and resolve on their own. However, up to 3% of UGIB deaths are a result of Mallory-Weiss tears. | *Most Mallory-Weiss tears are minor and resolve on their own. However, up to 3% of UGIB deaths are a result of Mallory-Weiss tears. | ||
*Endoscopy only for active and on-going bleeding<ref>Gyawali CP. The Washington Manual Gastroenterology Subspecialty Consult 2ed. 2008. Washington University School of Medicine.</ref> | |||
*Treat as undifferentiated Upper GI bleed. | *Treat as undifferentiated Upper GI bleed. | ||
**Many of these patients are alcoholics and have cirrhosis; consider esophageal varices | **Many of these patients are alcoholics and have cirrhosis; consider esophageal varices | ||
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*There is a mortality benefit in Asian patients<ref>Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; [http://www.thennt.com/nnt/proton-pump-inhibitors-for-acute-peptic-ulcer- bleeding/] </ref> | *There is a mortality benefit in Asian patients<ref>Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; [http://www.thennt.com/nnt/proton-pump-inhibitors-for-acute-peptic-ulcer- bleeding/] </ref> | ||
===[[Antibiotics]]=== | ===[[Antibiotics]]=== | ||
*[[Ceftriaxone]] 1gm daily | *If high suspicion of variceal bleeding or cirrhosis | ||
* | *Otherwise, prophylactic antibiotics before endoscopy not indicated in Mallory Weiss tears | ||
*[[Ceftriaxone]] 1gm daily x7 days | |||
*OR [[ciprofloxacin]] 500 mg PO or IV BID x7 days in quinolone-sensitive populations | |||
===[[Erythromycin]]=== | ===[[Erythromycin]]=== | ||
*Achieves endoscopy conditions equal to lavage<ref>Pateron D, et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Ann Emerg Med. 2011; 57(6):582-589.</ref> | *Achieves endoscopy conditions equal to lavage<ref>Pateron D, et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Ann Emerg Med. 2011; 57(6):582-589.</ref> | ||
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===Treatments Not Supported by the Literature=== | ===Treatments Not Supported by the Literature=== | ||
*No evidence to support octreotide use | *No evidence to support octreotide use | ||
==Disposition== | ==Disposition== | ||
Revision as of 16:50, 10 January 2016
Background
- Longitudinal lacerations through mucosa and submucosa
- 75% in proximal stomach, rest in distal esophagus
- Due to sudden increase in intrabdominal pressure
- Typically in the setting of forceful vomiting or retching
Clinical Presentation
Risk Factors
- Hiatal hernia
- Alcoholism
- Anything that increases intrabdominal pressure: blunt abdominal trauma, CPR, etc.
History
- Classic presentation: Hematemesis following vomiting or retching
- As few as 30% of patients present this way
- Coffee ground emesis
- Melena
- Hematochezia
Differential Diagnosis
Upper GI Bleed Differential
- Peptic ulcer disease
- Gastritis/esophagitis
- Gastric/esophageal varices
- Mallory-Weiss tear
- Malignancy
- Aortoenteric fisulta
- Boerhaave
- Dieulafoy's lesion
- Angiodysplasia
- Hemobilia
- Hemorrhagic gastritis, EtOH
- Celiac
- Dengue
- Other intrabdominal bleeds
- Hemorrhagic pancreatitis
- Splenic rupture
- Subcapsular cavernous hemangiomas
- Peliosis hepatis
Mimics of GI Bleeding
- Hemoptysis
- Vaginal/Urethra bleeding
- ENT bleeding
- Dietary (Iron, bismuth, beets)
Diagnosis
- Approach as any GI bleed
- POC Hgb
- CBC
- Type and screen
- Chemistry
- Guiac
- CXR
- Definitive diagnosis by endoscopy
Management
- Most Mallory-Weiss tears are minor and resolve on their own. However, up to 3% of UGIB deaths are a result of Mallory-Weiss tears.
- Endoscopy only for active and on-going bleeding[1]
- Treat as undifferentiated Upper GI bleed.
- Many of these patients are alcoholics and have cirrhosis; consider esophageal varices
- History of vomiting/retching; consider boerhaave
- Place 2 large bore IVs and monitor airway status
Proton Pump Inhibitor
- Pantoprazole/esomeprazole 80mg x 1; then 8mg/hr
- Reduces the rate of rebelling and need for surgery if there is an ulcer, but does not reduce morbidity or mortality[2]
- There is a mortality benefit in Asian patients[3]
Antibiotics
- If high suspicion of variceal bleeding or cirrhosis
- Otherwise, prophylactic antibiotics before endoscopy not indicated in Mallory Weiss tears
- Ceftriaxone 1gm daily x7 days
- OR ciprofloxacin 500 mg PO or IV BID x7 days in quinolone-sensitive populations
Erythromycin
- Achieves endoscopy conditions equal to lavage[4]
- 3mg/kg IV over 20-30min, 30-90min prior to endoscopy
IVF
- Crystalloid can be used for initial resuscitation but should be limited due to the dilutional anemia and dilatational coagulopathy that can result
PRBC transfusions
- Indications for PRBC transfusions:
- Hemoglobin <7 g/dl
- Continued active bleeding
- Failure to improve perfusion and vital signs after infusion of 2L NS
- Varicele bleeding[5]
- In hemodynamically stable patients, the goal transfusion threshold should be 7 g/dl
- NICE guidelines recommend avoidance of over-transfusion[6]
Other Blood Products
- Prothrombin complex concentrates[7]
- Cryopprecipitate to raise fibrinogen (goal >120mg/dL)
- Platelets (goal >50-100k/μL
- FFP can be used to correct anti coagulated patients
Endoscopy
- Endoscopy should be performed at the discretion of the gastroenterologist. Early endoscopy does not necessarily improve clinical outcomes[8]
Balloon tamponade with Sengstaken-Blakemore Tube
- For life-threatening hemorrhage if endoscopy is not available)
- Tube consists of gastric and esophageal balloons
- First inflate gastric balloon; if bleeding continues inflate esophageal balloon
- Esophageal pressure must not exceed 40-50 mmHg
- First inflate gastric balloon; if bleeding continues inflate esophageal balloon
- Adverse reactions are frequent
- Mucosal ulceration
- Esophageal/gastric rupture
- Tracheal compression (consider intubation prior to balloon insertion)
Treatments Not Supported by the Literature
- No evidence to support octreotide use
Disposition
- Anticipate admission
See Also
Upper gastrointestinal bleeding
External Links
References
- ↑ Gyawali CP. The Washington Manual Gastroenterology Subspecialty Consult 2ed. 2008. Washington University School of Medicine.
- ↑ Leontiadis GI et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2004(3):CD002094.
- ↑ Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; bleeding/
- ↑ Pateron D, et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Ann Emerg Med. 2011; 57(6):582-589.
- ↑ Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
- ↑ Dworzynski K et al. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012;344:e3412.
- ↑ Makris M, et al. Warfarin anticoagulation reversal: management of the asymptomatic and bleeding patient. J Thromb Thrombolysis. 2010; 28:171–181.
- ↑ Sarin N et al. Time to endoscopy and out- comes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-493.