Mallory-Weiss Syndrome Flashcards
What is the main cause of Mallory-Weiss tears (MWTs) at the gastroesophageal junction (GEJ)?
Forceful retching and vomiting
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vertical mucosal lacerations at the GEJ
what other factors can lead to Mallory-Weiss tears?
Rigid and flexible endoscopy injury
blunt abdominal trauma
prolonged coughing
persistent hiccups
and tonic-clonic seizures.
What physiological change occurs during forceful vomiting that leads to Mallory-Weiss tears (MWTs)?
A sudden increase in the resting pressure gradient between the abdominal and thoracic cavities
What happens to the pyloric channel and lower esophageal sphincter during forceful vomiting?
The pyloric channel tightens, while the lower esophageal sphincter, gastric cardia, and diaphragmatic hiatus relax
How does forceful vomiting result in mucosal tearing at the gastroesophageal junction (GEJ)?
Retrograde prolapse of proximal stomach mucosa into the esophageal lumen causes tearing of the gastric and sometimes esophageal mucosa
What role does intragastric pressure play in the formation of Mallory-Weiss tears?
Sudden increases in intragastric pressure and relaxation of the gastric cardia lead to dilation and tension-related linear lacerations at the GEJ
Where are Mallory-Weiss tears typically located in patients without a paraesophageal hernia?
At the GEJ, commonly along the lesser curvature of the stomach
What is a common lifestyle factor associated with Mallory-Weiss tear bleeding?
recent or active history of alcohol use
How does liver disease or cirrhosis affect MWT-associated bleeding?
tend to experience more severe bleeding from MWT.
paraesophageal hernia may be associated with MWTs involving
the gastric cardia alone.
What is the typical presentation of a patient with Mallory-Weiss tear (MWT) bleeding?
Acute history of forceful, nonbloody vomiting followed by hematemesis
What is the standard diagnostic tool for confirming MWT?
Flexible endoscopy, specifically esophagogastroscopy with retroflexed views of the GEJ and Cardia
What is the typical size range for Mallory-Weiss tears?
MWTs usually range from 0.5 to 2.5 cm in length, but some can reach up to 5 cm
Why is a complete evaluation of the esophagus, stomach, and duodenum important in MWT patients?
To check for other potential sources of upper gastrointestinal bleeding (UGIB) such as varices, gastritis, or peptic ulcers
What other diagnostic tests are available for UGIB besides endoscopy?
Tagged red blood cell scan
direct angiography
multidetector CT angiography.
How can direct angiography be used in patients actively bleeding from MWT?
Angiography of the left gastric or inferior phrenic artery may show a linear contrast collection at the GEJ
What is the first priority in managing a patient with upper gastrointestinal bleeding (UGIB)?
Evaluating for hemodynamic instability before diagnostic studies or interventions.
Which laboratory tests should be conducted immediately in UGIB patients?
Blood typing
cross-matching for transfusion
complete blood count
coagulation parameters
and a comprehensive metabolic panel with liver function
How should coagulopathy in UGIB patients be managed?
Correct coagulopathy promptly, especially if due to liver disease or anticoagulation therapy, using appropriate agents
What type and size of IV access is preferred for patients with active UGIB?
Large bore peripheral venous access, such as a 14- or 16-gauge catheter
What should be done if peripheral venous access cannot be established in a UGIB patient in hemorrhagic shock?
Place a central venous catheter (e.g., 8.5 French) for blood product resuscitation.
What role does a nasogastric (NG) tube play in UGIB management?
A dual or triple lumen 18 French NG tube decompresses the stomach, confirms UGIB, and clears blood before upper endoscopy
Why is gastric acid suppression used in UGIB patients
High-dose proton pump inhibitors decrease the need for endoscopic intervention, reduce transfusion requirements, and aid in mucosal healing
Why might platelet transfusion be necessary in some UGIB patients?
Patients with thrombocytopenia or on antiplatelet therapy may require platelet transfusion to improve clotting
Where should UGIB patients with critical organ perfusion status be monitored?
In a critical care unit with invasive monitoring
What is the success rate of endoscopic treatment for Mallory-Weiss tear (MWT) bleeding?
99% of patients with MWT-associated bleeding achieve successful treatment with endoscopy
What role does gastroscopy with retroflexed visualization play in MWT management?
It is essential for diagnosing and treating MWT by allowing direct visualization of the gastroesophageal junction (GEJ).
How are non-bleeding Mallory-Weiss tears managed?
With antiacid therapy alone for 2 weeks
repeat endoscopy is not required for confirmation of healing
What are common endoscopic techniques for treating active bleeding from MWT?
Hemoclip
ligation banding
thermal coagulation
and injection of sclerosing or vasoconstricting agents
How does dilute epinephrine work in MWT treatment?
Injection of 15 to 30 mL of 1:10,000 epinephrine causes local vasoconstriction to stop bleeding
What are potential risks associated with sclerosing agents like cyanoacrylate for MWT?
They can cause tissue necrosis leading to perforation if injected too deeply
Why is hemoclip placement often combined with epinephrine or sclerosant injection?
To further decrease the risk of rebleeding from MWT.
What thermal coagulation techniques are used for MWT bleeding?
Monopolar or bipolar electrical energy and argon plasma coagulation (APC)
What is the advantage of using over-the-scope clip devices in MWT treatment?
They allow tangential clip placement, which is highly effective for controlling MWT bleeding
When is transcatheter arterial embolization or vasopressin infusion considered for MWT?
In patients who are poor surgical candidates and have not responded to endoscopic treatment
Why has angioembolization replaced vasopressin infusion in MWT treatment?
Vasopressin infusion has a higher risk of recurrent bleeding compared to angioembolization.
What materials are used in selective angioembolization for MWT bleeding?
Microspheres, small coils, or glue are injected into the bleeding vessel.
Why is active vessel extravasation during angiography uncommon in hemodynamically unstable MWT patients?
Generalized vasoconstriction from hypovolemia or temporary thrombus formation often prevents visible extravasation
What is provocative angiography, and how does it help in MWT management?
It involves injecting vasodilators or anticoagulants (e.g., heparin) to induce bleeding and identify the bleeding vessel.
Which arteries are typically involved in bleeding from a Mallory-Weiss tear?
The left gastric artery or inferior phrenic artery
When might empiric embolization be used in MWT cases?
If angiography fails to identify active extravasation, empiric embolization of the suspected arteries may be necessary.
How does the rebleeding rate of angioembolization compare to surgical treatment for MWT?
Angioembolization has a higher rebleeding rate than surgical treatment
Why might nonselective angioembolization be performed in MWT patients?
It may be indicated for patients who are poor candidates for surgery.
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How successful is endoscopic therapy for MWT-related upper gastrointestinal bleeding (UGIB)?
It is successful in 99% of UGIB cases caused by MWT
What should be attempted before proceeding to surgery if initial endoscopic therapy for MWT fails?
A second endoscopic procedure with an experienced endoscopist
How is the bleeding site prepared for surgery in MWT cases?
The location is identified by endoscopy, followed by a high anterior longitudinal gastrotomy for visualization of the tear.
How is the Mallory-Weiss tear repaired surgically?
The tear is oversewn within the gastric lumen using absorbable sutures
What technique is used if massive hemorrhage prevents visualization of the MWT during surgery?
Direct tamponade with a sponge stick to stop bleeding and allow time for resuscitation
Why is it important to examine for other lesions after repairing an MWT surgically?
Because most MWT cases that require surgery also have other lesions.
How is the anterior gastrotomy closed after MWT repair?
It is closed in two layers.
What measure is taken during gastric closure to prevent gastric inlet obstruction at the GEJ?
A large transoral bougie is placed to prevent narrowing
