Anatomy, esophagus

Esophagus, Tear
Mallory-Weiss tear
Mallory-Weiss syndrome is characterized by upper
gastrointestinal bleeding secondary to longitudinal mucosal
lacerations at the:
* gastroesophageal junction or
gastric cardia

The original description by Mallory and Weiss in 1929

1) Involved patients with persistent:
retching and
vomiting
following an alcoholic binge
 Esophagus, Tear
Mallory-Weiss tear
Typically video endoscopic Illustration
 Esophagus, Tear

Mallory-Weiss tear
2) However, Mallory-Weiss syndrome may occur
after any event that provokes a sudden rise in:
* intragastric pressure or
* gastric prolapse into the esophagus
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Mallory-Weiss tear
Pathophysiology:
3) A Mallory-Weiss tear (MWT) likely occurs as a
result of:
* a large
* rapidly occurring and
* transient transmural pressure gradient across
the region of the gastroesophageal junction
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Mallory-Weiss tear
Pathophysiology:

4) Acute distension of the nondistensible lower

esophagus can also produce a linear tear in this
region
 Mallory-Weiss tear
Pathophysiology:
5) Hiatal hernia
With a rapid rise in intragastric pressure due to precipitating
factors, such as:
retching or
vomiting
the transmural pressure gradient increases dramatically
across the hiatal hernia

If the shearing forces are high enough, a longitudinal

laceration eventually occurs
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Mallory-Weiss tear
Pathophysiology:
Within the hernia, the tear is more likely to involve
the lesser curvature of the gastric cardia, which is
relatively immobile compared to the remainder of the
stomach
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Mallory-Weiss tear
Pathophysiology:
6) Another potential mechanism for MWTs is the
violent prolapse or intussusception of the upper
stomach into the esophagus

as can be witnessed during forceful retching at

endoscopy
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Mallory-Weiss tear
Frequency:
MWTs account for 1-15% of cases of upper gastrointestinal bleeding
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Mallory-Weiss tear
Mortality/Morbidity:
Bleeding from MWTs stops spontaneously in 80-
90% of patients

With conservative therapy, most tears heal

uneventfully within 48 hours

Thus, a MWT can easily be missed if endoscopy is

delayed
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Mallory-Weiss tear
Mortality/Morbidity
Current clinical experience suggests a significantly
lower mortality rate from MWTs

Sex: Most studies report a male predominance Male-

to-female ratios reportedly are 2-4:1

Age: Patients usually present in their 40s or 50s

But the age range is quite wide
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Mallory-Weiss tear
Clinical Presentation
History
The classic presentation consists of an episode of
hematemesis following a bout of:
retching or
vomiting

although this presentation may be less common than

previously thought
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Mallory-Weiss tear
Clinical Presentation
History
Previous studies found that a typical history was
obtained in only about 30% of patients

And hematemesis on first emesis was reported in

50% of patients
Clinical Presentation (Mallory-Weiss tear)
History
Hematemesis is present in 85% of patients

Less common presenting symptoms include: melena,

hematochezia, syncope, and abdominal pain

* excessive alcohol use has been reported in 40-75%

of patients, and
* aspirin use in up to 30%

Attempt to identify a precipitating factor for the MW

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Mallory-Weiss tear
Physical Examination
MWTs do not elicit specific physical signs

Physical findings relate to the:

* rate and
* degree of gastrointestinal blood loss

Tachycardia, hypotension, orthostatic changes, or overt

shock may be evident
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Mallory-Weiss tear
Causes:
The presence of a hiatal hernia is a predisposing factor
and is found in 35-100% of patients with MWTs

Precipitating factors include:

* retching * hiccuping
* vomiting * coughing
* straining * primal scream therapy
* blunt abdominal trauma and
* cardiopulmonary resuscitation
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Mallory-Weiss tear
Causes:
Iatrogenic tears are uncommon

considering the frequency with which patients retch

during endoscopy

The reported prevalence is 0.07-0.49%

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Mallory-Weiss tear
Causes:
In a few cases, no apparent precipitating factor can
be identified

In one study, 25% of patients had no identifiable

risk factor
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Mallory-Weiss tear
Differential Diagnosis

Boerhaave Syndrome
Esophagitis

Gastric Ulcers
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Mallory-Weiss tear
Diagnosis Workup
Lab Studies
* hemoglobin and
* hematocrit studies
are performed to assess the:
* severity of the initial bleeding episode and
* to monitor patients
Mallory-Weiss tear
Diagnosis Workup
Lab Studies
* platelet count
* prothrombin time and
* activated partial thromboplastin time
are performed to assess for severe:
* thrombocytopenia and
* coagulopathy
Mallory-Weiss tear
Diagnosis Workup
Lab Studies
* BUN
* creatinine and
* electrolyte levels
are measured to guide intravenous fluid therapy
Mallory-Weiss tear
Diagnosis Workup
Lab Studies
* Blood type and
* antibody screen
are obtained for potential blood transfusions
Mallory-Weiss tear
Diagnosis Workup
Imaging Studies
* Barium or
* Gastrografin studies
should not be performed owing to their:
* low diagnostic sensitivity and
* interference with endoscopic assessment and
therapy
Mallory-Weiss tear
Diagnosis Workup
Other Tests
ECG
To assess for myocardial ischemia related to acute
gastrointestinal blood loss, especially in patients with
significant:
* anemia
* hemodynamic instability
* cardiovascular disease
* coexisting chest pain, and/or
* advanced age
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Procedures
Perform endoscopy early in the clinical course

Endoscopy is the procedure of choice for both:

diagnosis and
therapy
Mallory-Weiss tear
Procedures
Endoscopic diagnosis of a MWT is readily made by
identifying:
* active bleeding
* an adherent clot or
* a fibrin crust

over a mucosal split within or near the

gastroesophageal junction
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Procedures
On average, the split is:
2-3 cm in length and
a few millimeters in width

Most patients (>80%) present with a single tear

Mallory-Weiss tear
Procedures
The usual location of the tear is just below the
gastroesophageal junction on the lesser
curvature of the stomach

between 2 and 6 o'clock on endoscopic viewing

with the patient in the left lateral decubitus
position
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Treatment
Medical Care:
Initial management consists of implementing
resuscitative measures as appropriate

performing endoscopy promptly, and triaging patients to:

a) intensive care, b) hospital inpatient, or c) outpatient
management, depending on the severity of:
* bleeding
* comorbidities and
* risk of rebleeding and complications
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Treatment
Medical Care:
Most patients have stopped bleeding at the time of
endoscopy

Five to 35% of patients require some form of

intervention, mostly endoscopic
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Treatment
Medical Care:
Otherwise, supportive care with volume and/or blood
replacement, acid suppression (e.g. omeprazole)

Antiemetic drug therapy (e.g. prochlorperazine)

is sufficient in most patients presenting with a MWT
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Treatment
Surgical Care:
Surgical oversewing of the tear is reserved for the
occasional bleeding case refractory to:
1) endoscopic therapy or
2) angiotherapy
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