Mallory-Weiss tear

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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 Features

Risk Factors

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

Mimics of GI Bleeding

Evaluation

  • Approach as any GI bleed
    • CBC
    • BMP
    • Type and screen
    • Guiac
    • CXR
  • Definitive diagnosis by endoscopy

Management

  • Most Mallory-Weiss tears are minor and resolve on their own, but up to 3% of upper gastrointestinal bleeding 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

Resuscitation

  • Place 2 large bore IVs and monitor airway status

Proton Pump Inhibitor

  • Pantoprazole/esomeprazole 80mg x 1; then 8mg/hr
  • Intermittent dosing of pantoprazole, esomeprazole, or omeprazole 40 mg IV BID not inferior to continuous infusion dosing[2]
  • Reduces the rate of re-bleeding and need for surgery if there is an ulcer, but does not reduce morbidity or mortality[3][4]
  • There is a mortality benefit in Asian patients[5]

Erythromycin

  • Achieves endoscopy conditions equal to lavage[6]
  • 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

In hemodynamically stable patients, the goal transfusion threshold should be 7 g/dl; NICE guidelines recommend avoidance of over-transfusion[7]

Indications:

  • Hemoglobin <7 g/dl
  • Continued active bleeding
  • Failure to improve perfusion and vital signs after infusion of 2L NS
  • Varicele bleeding[8]

Other Blood Products

Endoscopy

  • Endoscopy should be performed at the discretion of the gastroenterologist; within 12 hrs for variceal bleeding[11]

Early endoscopy does not necessarily improve clinical outcomes[12]

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
  • 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

External Links

References

  1. Gyawali CP. The Washington Manual Gastroenterology Subspecialty Consult 2ed. 2008. Washington University School of Medicine.
  2. Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(11):1755.
  3. Leontiadis GI et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2004(3):CD002094.
  4. Sreedharan A et al. Proton Pump Inhibitor Treatment Initiated Prior to Endoscopic Diagnosis in Upper Gastrointestinal Bleeding (Review). Cochrane Database Syst Rev 2010; (7): CD005415. PMID: 20614440
  5. Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; bleeding/
  6. 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.
  7. Dworzynski K et al. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012;344:e3412.
  8. Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  9. Makris M, et al. Warfarin anticoagulation reversal: management of the asymptomatic and bleeding patient. J Thromb Thrombolysis. 2010; 28:171–181.
  10. Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  11. Kim YD. Management of acute variceal bleeding. Clin Endosc. 2014; 47(4):308–314.
  12. Sarin N et al. Time to endoscopy and out- comes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-493.