Mallory-Weiss syndrome

Mallory-Weiss syndrome is characterized by acute upper gastrointestinal bleeding caused by mucous membrane lacerations at the gastroesophageal junction; lacerations may also extend above and/or below the junction. These lacerations are often caused by forceful vomiting in patients with gastric mucosal injury, usually related to heavy alcohol use. Patients typically present with a history of epigastric pain and hematemesis. Patients with severe bleeding may be hemodynamically unstable and, therefore, immediate hemodynamic support (e.g., IV fluid resuscitation and/or blood transfusion) may be necessary. EGD is used in both the diagnosis of Mallory-Weiss syndrome and its treatment, as it may involve simultaneous hemostasis. If EGD is unsuccessful, angiography may be considered; surgery is rarely required. Pharmacological treatment (e.g., antiemetic therapy, acid suppression) should be initiated in all patients with Mallory-Weiss syndrome; further treatment is often not required in patients without active bleeding.

• Sex: ♂ > ♀ (3:1)
• Mallory-Weiss lesions account for approx. 5% of cases of gastrointestinal bleeding ^[1]

Epidemiological data refers to the US, unless otherwise specified.

• Mechanism: a sudden and severe rise in the esophageal intraluminal pressure results in tearing of the esophageal mucous membrane, as well as the submucosal arteries and veins
• Precipitating factors
  • Severe vomiting
  • Blunt abdominal trauma
  • Strained defecation
• Predisposing conditions
  • Alcohol use disorder
  • Bulimia nervosa
  • Hiatal hernia (higher pressure gradient)
  • Gastroesophageal reflux disease (GERD)

• May be asymptomatic
• Epigastric or back pain
• Hematemesis
• Possible shock with massive hemorrhage

Approach ^{[2][3][4][5][6]}

Suspect Mallory-Weiss syndrome in patients with upper GI bleeding and a history of precipitating factors or predisposing conditions; see “Etiology.”

• Follow a diagnostic approach for overt GI bleeding.
  • Perform an ABCDE survey and assess for clinical features of shock.
  • Obtain an initial diagnostic workup.
    • Assess for high-risk features of GI bleeding (e.g., anemia, coagulopathy, ↑ BUN).
    • Rule out differential diagnoses (e.g., acute coronary syndrome).
• Confirm the diagnosis.
  • Consult gastroenterology for EGD.
  • Consider angiography if EGD is unsuccessful or unavailable.

Blood loss may initially be concealed because of the large volume of the GI tract.

Initial studies ^[4]

• CBC: may reveal anemia and/or thrombocytopenia
• Coagulation studies: may reveal coagulopathy (see also “Laboratory findings in bleeding disorders”)
• BMP: may show ↑ BUN:creatinine ratio
• Pretransfusion testing: blood typing and crossmatching
• Cardiac enzymes and bedside ECG: to rule out acute coronary syndrome

EGD ^{[2][3][5][7][8]}

EGD is the gold standard test and can rule out other differential diagnoses of upper GI bleeding.

• Indications
  • Should be performed in all patients to confirm the diagnosis
  • The need for urgent evaluation will depend on the severity of the bleeding; see “Glasgow-Blatchford bleeding score.”
• Typical findings
  • Often a single longitudinal tear (but multiple tears are possible) in the mucosa at the gastroesophageal junction; or in the cardia of the stomach which are limited to the mucosa and submucosa
  • A fibrin crust over the split, a clot, or active bleeding may be evident.

MaLLory-Weiss: Longitudinal Lacerations

Angiography ^[3][5][6][9]

• Indications
  • Signs of active bleeding without successful location of the tear on EGD
  • EGD unavailable
• Typical findings: contrast extravasation at the site of active bleeding

See “Differential diagnoses of upper GI bleeding” for details.

• Boerhaave syndrome
• Esophagitis
• Esophageal ulcers
• Peptic ulcer disease

The differential diagnoses listed here are not exhaustive.

There are no specific guidelines for the management of Mallory-Weiss syndrome; recommendations are based on guidelines for the management of upper GI bleeding. ^[2][5][6][8]

Approach ^[2][4][5][6]

• Start initial management of overt GI bleeding, potentially including:
  • Immediate hemodynamic support
  • Emergency blood transfusion and correction of coagulopathy
  • Empiric medical therapy for GI bleeding
• Start pharmacological therapy: to control precipitating factors and predisposing conditions (e.g., nausea and/or vomiting)
• Evaluate the need for interventional therapy.
  • In patients without active bleeding, noninterventional management is often sufficient.
  • Consult specialists early (e.g., gastroenterology, interventional radiology )
• Treat the underlying condition: e.g., counseling on alcohol use disorder , treatment of bulimia nervosa

The use of large volumes of IV fluid during resuscitation in patients with ongoing bleeding increases the risk of dilutional coagulopathy, which can worsen the hemorrhage. Consider blood products early.

Pharmacological treatment ^[2][5][6]

The goal is to promote mucosal recovery.

• Acid suppression
  • IV PPI therapy: e.g., esomeprazole or high-dose esomeprazole (off label) ^[10]
    • Consider prior to EGD as part of empiric medical therapy for GI bleeding.
    • Consider continuation for 72 hours after endoscopy in patients at high risk for rebleeding.
  • Oral PPI therapy (e.g., omeprazole or pantoprazole )
    • Initiate in all patients after IV PPI therapy has been discontinued (off-label use).
    • The recommended dosage (e.g., every 12–24 hours) and duration (e.g., 2–8 weeks) of therapy varies; consult a specialist.
• Anticoagulant reversal: Consider for life-threatening bleeding.
• Antiemetic therapy (e.g., ondansetron, promethazine): Consider in patients with nausea, retching, and/or vomiting.

Initiation of pharmacological therapy should not delay endoscopy.

Conservative treatment with PPI therapy alone is usually sufficient for patients without active bleeding.

Endoscopic treatment ^{[2][3][5][6][8]}

• Indication: first-line treatment for actively bleeding Mallory-Weiss tears
• Techniques ^[5]
  • Injection of an epinephrine solution; or a fibrin sealant
  • Electrocoagulation or argon plasma coagulation
  • Endoscopic band ligation
  • Hemoclip placement

Angiographic treatment ^{[3][4][5][6][9]}

• Indications
  • Second-line treatment for actively bleeding Mallory-Weiss tears if EGD is unsuccessful
  • Alternative to EGD in patients at high risk for endoscopic complications or if EGD is unavailable
• Techniques
  • Embolization of the left gastric artery
  • Vasopressin infusion

Surgical treatment ^[4][6]

• Indication: only considered if EGD and angiographic treatment are unsuccessful and bleeding is ongoing
• Technique: surgical ligation of bleeding vessels

• NPO
• ABCDE survey
• IV access
• Immediate hemodynamic support
  • IV fluid resuscitation
  • Blood transfusion and platelet transfusion (if applicable)
• Acid suppression with IV PPI therapy
• Consider anticoagulant reversal.
• Antiemetic therapy for patients with nausea and/or vomiting
• Initial studies
  • Routine studies: CBC, coagulation studies, BMP
  • Blood type and crossmatching
  • ECG and cardiac enzymes
• Gastroenterology consult for EGD
• Interventional radiology consult for angiography (if EGD is unsuccessful or unavailable)
• General surgery consult (if there is still active bleeding after EGD and angiography)
• Serial CBC; monitoring for signs of bleeding
• Continuous pulse oximetry, frequent blood pressure measurement
• ICU admission for hemodynamically unstable patients
• Alcohol cessation counseling (if applicable)