UPTODATE
SUMMARY AND RECOMMENDATIONS
●Etiology and pathogenesis – Mallory-Weiss syndrome is characterized by longitudinal mucosal lacerations in the distal esophagus and proximal stomach secondary to a sudden increase in intra-abdominal pressure. Bleeding occurs when the tear involves the underlying esophageal venous or arterial plexus. Risk factors include alcohol use and hiatus hernia. Mallory-Weiss syndrome may be precipitated by vomiting, straining or lifting, coughing, seizures, blunt abdominal injury, nasogastric tube placement, and gastroscopy.
●Clinical features – Patients usually present with hematemesis (either red blood or coffee-ground emesis). Hematemesis may be accompanied by epigastric pain or pain in the back. Patients often have a history of nonbloody emesis, retching, or coughing prior to hematemesis.
●Diagnosis – Mallory-Weiss syndrome should be suspected in patients with upper gastrointestinal bleeding and a history of vomiting or retching. The diagnosis is established on endoscopy with visualization of a single, longitudinal mucosal tear at the esophagogastric junction. An upper endoscopy establishes the diagnosis, rules out other etiologies, and allows for therapeutic intervention.
●Management
•General measures
-Patients require urgent assessment of hemodynamic stability and may require supportive care including fluid resuscitation and/or blood transfusions, and antiemetics for management of persistent nausea or vomiting.
-In general, a high-dose twice-daily intravenous proton pump inhibitor (PPI) is administered to all patients with suspected clinically significant upper gastrointestinal bleeding prior to endoscopy as part of their initial management. In patients with Mallory-Weiss syndrome, we continue an oral PPI (eg, omeprazole 20 mg twice daily) in all patients for at least two weeks.
•Endoscopic evaluation and therapy – In patients with Mallory-Weiss tears with stigmata of recent hemorrhage on upper endoscopy, we recommend endoscopic therapy and acid suppressive therapy rather than acid suppressive therapy alone (Grade 1B). Stigmata of recent hemorrhage (active bleeding, visible vessel, or adherent clot) increase the risk of recurrent bleeding. Patients may be treated with thermal coagulation, endoscopic clips, or endoscopic band ligation (with or without epinephrine injection) (algorithm 1).
Mallory-Weiss tears without stigmata of recent hemorrhage can be managed with acid suppression alone. (See ‘Acid suppression’ above.)
●Hospitalization in patients at high risk for rebleeding and complications – We typically hospitalize and observe patients at high risk for rebleeding and its complications for 48 hours. This includes patients with any one of the following: •Risk factors for recurrent bleeding (portal hypertension, coagulopathy). •Endoscopic stigmata of recent bleeding (eg, active bleeding at the time of endoscopy, nonbleeding visible vessel, or adherent clot). •Severe upper gastrointestinal bleeding (hemodynamic instability, hematochezia, blood transfusion requirement). •Increased risk for complications should bleeding recur (eg, significant coronary artery or cerebrovascular disease). Patients without risk factors for rebleeding, endoscopic stigmata of recent bleeding, or clinical features indicating severe bleeding can be discharged following endoscopy.
●Patients with persistent bleeding – We suggest that patients who fail endoscopic therapy undergo transarterial angiographic embolization rather than surgery (Grade 2C).
●Prognosis – Mallory-Weiss syndrome tears heal rapidly. Patients do not require repeat endoscopic evaluation to document healing. Approximately 7 percent of patients with Mallory-Weiss syndrome have recurrent bleeding. Rebleeding can usually be managed endoscopically. The mortality rate is approximately 5 percent and depends upon patient age and the presence of coexisting medical conditions.