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A1-G Surg Note Stomach > Mallory-Weiss Syndrome > Flashcards

Mallory-Weiss Syndrome Flashcards

1
Q

What is the main cause of Mallory-Weiss tears (MWTs) at the gastroesophageal junction (GEJ)?

A

Forceful retching and vomiting
>
vertical mucosal lacerations at the GEJ

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2
Q

what other factors can lead to Mallory-Weiss tears?

A

Rigid and flexible endoscopy injury
blunt abdominal trauma
prolonged coughing
persistent hiccups
and tonic-clonic seizures.

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3
Q

What physiological change occurs during forceful vomiting that leads to Mallory-Weiss tears (MWTs)?

A

A sudden increase in the resting pressure gradient between the abdominal and thoracic cavities

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4
Q

What happens to the pyloric channel and lower esophageal sphincter during forceful vomiting?

A

The pyloric channel tightens, while the lower esophageal sphincter, gastric cardia, and diaphragmatic hiatus relax

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5
Q

How does forceful vomiting result in mucosal tearing at the gastroesophageal junction (GEJ)?

A

Retrograde prolapse of proximal stomach mucosa into the esophageal lumen causes tearing of the gastric and sometimes esophageal mucosa

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6
Q

What role does intragastric pressure play in the formation of Mallory-Weiss tears?

A

Sudden increases in intragastric pressure and relaxation of the gastric cardia lead to dilation and tension-related linear lacerations at the GEJ

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7
Q

Where are Mallory-Weiss tears typically located in patients without a paraesophageal hernia?

A

At the GEJ, commonly along the lesser curvature of the stomach

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8
Q

What is a common lifestyle factor associated with Mallory-Weiss tear bleeding?

A

recent or active history of alcohol use

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9
Q

How does liver disease or cirrhosis affect MWT-associated bleeding?

A

tend to experience more severe bleeding from MWT.

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10
Q

paraesophageal hernia may be associated with MWTs involving

A

the gastric cardia alone.

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11
Q

What is the typical presentation of a patient with Mallory-Weiss tear (MWT) bleeding?

A

Acute history of forceful, nonbloody vomiting followed by hematemesis

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12
Q

What is the standard diagnostic tool for confirming MWT?

A

Flexible endoscopy, specifically esophagogastroscopy with retroflexed views of the GEJ and Cardia

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13
Q

What is the typical size range for Mallory-Weiss tears?

A

MWTs usually range from 0.5 to 2.5 cm in length, but some can reach up to 5 cm

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14
Q

Why is a complete evaluation of the esophagus, stomach, and duodenum important in MWT patients?

A

To check for other potential sources of upper gastrointestinal bleeding (UGIB) such as varices, gastritis, or peptic ulcers

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15
Q

What other diagnostic tests are available for UGIB besides endoscopy?

A

Tagged red blood cell scan
direct angiography
multidetector CT angiography.

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16
Q

How can direct angiography be used in patients actively bleeding from MWT?

A

Angiography of the left gastric or inferior phrenic artery may show a linear contrast collection at the GEJ

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17
Q

What is the first priority in managing a patient with upper gastrointestinal bleeding (UGIB)?

A

Evaluating for hemodynamic instability before diagnostic studies or interventions.

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18
Q

Which laboratory tests should be conducted immediately in UGIB patients?

A

Blood typing
cross-matching for transfusion
complete blood count
coagulation parameters
and a comprehensive metabolic panel with liver function

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19
Q

How should coagulopathy in UGIB patients be managed?

A

Correct coagulopathy promptly, especially if due to liver disease or anticoagulation therapy, using appropriate agents

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20
Q

What type and size of IV access is preferred for patients with active UGIB?

A

Large bore peripheral venous access, such as a 14- or 16-gauge catheter

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21
Q

What should be done if peripheral venous access cannot be established in a UGIB patient in hemorrhagic shock?

A

Place a central venous catheter (e.g., 8.5 French) for blood product resuscitation.

22
Q

What role does a nasogastric (NG) tube play in UGIB management?

A

A dual or triple lumen 18 French NG tube decompresses the stomach, confirms UGIB, and clears blood before upper endoscopy

23
Q

Why is gastric acid suppression used in UGIB patients

A

High-dose proton pump inhibitors decrease the need for endoscopic intervention, reduce transfusion requirements, and aid in mucosal healing

24
Q

Why might platelet transfusion be necessary in some UGIB patients?

A

Patients with thrombocytopenia or on antiplatelet therapy may require platelet transfusion to improve clotting

25
Q

Where should UGIB patients with critical organ perfusion status be monitored?

A

In a critical care unit with invasive monitoring

26
Q

What is the success rate of endoscopic treatment for Mallory-Weiss tear (MWT) bleeding?

A

99% of patients with MWT-associated bleeding achieve successful treatment with endoscopy

27
Q

What role does gastroscopy with retroflexed visualization play in MWT management?

A

It is essential for diagnosing and treating MWT by allowing direct visualization of the gastroesophageal junction (GEJ).

28
Q

How are non-bleeding Mallory-Weiss tears managed?

A

With antiacid therapy alone for 2 weeks

repeat endoscopy is not required for confirmation of healing

29
Q

What are common endoscopic techniques for treating active bleeding from MWT?

A

Hemoclip
ligation banding
thermal coagulation
and injection of sclerosing or vasoconstricting agents

30
Q

How does dilute epinephrine work in MWT treatment?

A

Injection of 15 to 30 mL of 1:10,000 epinephrine causes local vasoconstriction to stop bleeding

31
Q

What are potential risks associated with sclerosing agents like cyanoacrylate for MWT?

A

They can cause tissue necrosis leading to perforation if injected too deeply

32
Q

Why is hemoclip placement often combined with epinephrine or sclerosant injection?

A

To further decrease the risk of rebleeding from MWT.

33
Q

What thermal coagulation techniques are used for MWT bleeding?

A

Monopolar or bipolar electrical energy and argon plasma coagulation (APC)

34
Q

What is the advantage of using over-the-scope clip devices in MWT treatment?

A

They allow tangential clip placement, which is highly effective for controlling MWT bleeding

35
Q

When is transcatheter arterial embolization or vasopressin infusion considered for MWT?

A

In patients who are poor surgical candidates and have not responded to endoscopic treatment

36
Q

Why has angioembolization replaced vasopressin infusion in MWT treatment?

A

Vasopressin infusion has a higher risk of recurrent bleeding compared to angioembolization.

37
Q

What materials are used in selective angioembolization for MWT bleeding?

A

Microspheres, small coils, or glue are injected into the bleeding vessel.

38
Q

Why is active vessel extravasation during angiography uncommon in hemodynamically unstable MWT patients?

A

Generalized vasoconstriction from hypovolemia or temporary thrombus formation often prevents visible extravasation

39
Q

What is provocative angiography, and how does it help in MWT management?

A

It involves injecting vasodilators or anticoagulants (e.g., heparin) to induce bleeding and identify the bleeding vessel.

40
Q

Which arteries are typically involved in bleeding from a Mallory-Weiss tear?

A

The left gastric artery or inferior phrenic artery

41
Q

When might empiric embolization be used in MWT cases?

A

If angiography fails to identify active extravasation, empiric embolization of the suspected arteries may be necessary.

42
Q

How does the rebleeding rate of angioembolization compare to surgical treatment for MWT?

A

Angioembolization has a higher rebleeding rate than surgical treatment

43
Q

Why might nonselective angioembolization be performed in MWT patients?

A

It may be indicated for patients who are poor candidates for surgery.

44
Q

Algo

A

see

45
Q

How successful is endoscopic therapy for MWT-related upper gastrointestinal bleeding (UGIB)?

A

It is successful in 99% of UGIB cases caused by MWT

46
Q

What should be attempted before proceeding to surgery if initial endoscopic therapy for MWT fails?

A

A second endoscopic procedure with an experienced endoscopist

47
Q

How is the bleeding site prepared for surgery in MWT cases?

A

The location is identified by endoscopy, followed by a high anterior longitudinal gastrotomy for visualization of the tear.

48
Q

How is the Mallory-Weiss tear repaired surgically?

A

The tear is oversewn within the gastric lumen using absorbable sutures

49
Q

What technique is used if massive hemorrhage prevents visualization of the MWT during surgery?

A

Direct tamponade with a sponge stick to stop bleeding and allow time for resuscitation

50
Q

Why is it important to examine for other lesions after repairing an MWT surgically?

A

Because most MWT cases that require surgery also have other lesions.

51
Q

How is the anterior gastrotomy closed after MWT repair?

A

It is closed in two layers.

52
Q

What measure is taken during gastric closure to prevent gastric inlet obstruction at the GEJ?

A

A large transoral bougie is placed to prevent narrowing

A1-G Surg Note Stomach (11 decks)

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