Mallory-Weiss Tear

Question 1

What is a Mallory-Weiss tear?

Answer 1

A tear or laceration often along the right border of, or near, the gastro-oesophageal junction. Patients present with non-variceal upper GI bleeding. The haemorrhage is usually self-limited, ceasing spontaneously in 80% to 90% of patients.

Question 2

How common are Mallory-Weiss tears?

Answer 2

• MWT represent 3-15% of cases of upper GI bleeding
• More common in men (3:1)
• Less common in children
• Usually 30-50 year olds
• Can be caused by hyperemesis gravidarum in pregnant women

Question 3

What is the aetiology of Mallory-Weiss tears?

Answer 3

Predisposing factors include:

• vomiting or conditions whcih cause vomiting
• hiatus hernias (present in >40% of patients with MWT)
• coughing, retching, straining, hiccups
• closed-chest pressure, CPR, acute abdominal blunt trauma, alcohol, medications

Question 4

List 5 different causes of vomiting.

Answer 4

• Gi disease e.g. food poisoning
• Hyperemesis gravidarum
• Renal disease e.g. renal failure
• Neurological disease e.g. meningitis
• Psychiatric illness e.g. anorexia nervosa, bullimia
• Toxic agents e.g. bowel prep (polyethylene glycol), chemotherapy

Question 5

What is the pathophysiology of MWT?

Answer 5

Sudden rise in abdominal pressure/transmural pressure gradient across gastro-oesophageal junction with a corresponding low intrathoracic pressure

When forces are high enough to cause distension in this poorly distended area, laceration/ acute GO tear may occur.

Question 6

What are the symptoms of MWT?

Answer 6

The classic presentation =

• Small and self-limited episode of haematemesis,
• Bleed varies from streaks of blood mixed with gastric contents and/or mucus, and blackish or ‘coffee grounds’, to a bright-red bloody emesis
• After a bout of retching, or any other factors that increase pressure at the level of the GOJ.
• Light headedness/dizziness
• Other - odynophagia, melaena, shock, anaemia.

Question 7

What are the signs of MWT on examination?

Answer 7

• Orthostatic changes in BP
• Tachycardia
• Hypotension
• Shock (rare)

Question 8

What investigations would you do for MWT?

Answer 8

Rapid intervention is key:

• Calculate Glasgow-Blatchford score
• FBC - check Hb for possible transfusion need if <70g/L; platelets if <50x109/L
• Group and save/ crossmatch
• OGD - DIAGNOSTIC and therapeutic; should be performed after stabilisation; shows red longitudinal defect with normal surrounding mucosa of variable size
• PR - examine for melaena or haematochezia (undigested blood PR)

Other:

• Urea - high in active bleeding
• LFTs - normal unless coexisting liver disease
• PT/INR/PTT
• CXR - exclude oesophageal perforation
• CT - if suspecting peritonitis

Question 9

What is the management of MWT?

Answer 9

Resuscitation and monitoring

Stop anticoagulants, reverse warfarin - idarucizumab against dabigatran, andexanet alfa in patients taking anti-factor Xa, vitamin K IV and four-factor prothrombin complex concentrate. Generally continue aspirin, stop NSAIDs.

Cyclizine/promethazine - anti-emetics to stop vomiting aggravating MWT

Blood transfusion - if Hb <70g/L

OGD +/- intervention within 12-24hrs -

• haemoclip placement +/- adrenaline injected around bleeding point
• OR thermocoagulation therapy
• OR endoscopic band ligation (EBL)+adrenaline

If all fails then surgery - involved vasopressin injection into SMA/LGA or into bleeding artery and transcatheter embolisation e.g. with gelfoam.

PPI e.g. 80mg IV omeprazole initially - recommended if sign of bleeding on endoscopy

Emergency surgery - although usually only considered after endoscopy has been repeated

Question 10

What are the complications of a MWT?

Answer 10

• Re-bleeding
• MI
• Hypovolaemic shock/death
• Oesophageal perforation - high mortality secondary to rapidly developing mediastinitis and sepsis.
• Metabolic disturbance - initial electrolyte evaluation and rapid replacement is imperative in patients with intractable vomiting

Question 11

What is the prognosis in MWT?

Answer 11

Self-limiting in most or will have stopped by the time of endoscopy

8-15% of patients get rebleeding - usually in first 24hours

Question 12

What are the risk factors for MWT?

Answer 12

• Conditions predisposing to retching, vomiting, straining
• Chronic cough
• Hiatal hernia
• Retching during endoscopy etc
• Significant alcohol use
• Hiccups
• Male
• Age 30-50 years
• Aspirin/NSAID use
• blunt abdo trauma
• Primal scream therapy

Question 13

What are the reversal agents for:

• warfarin
• dabigatran
• apixaban

Answer 13

idarucizumab against dabigatran,

andexanet alfa in patients taking anti-factor Xa (e.g. apixaban)

vitamin K IV and four-factor prothrombin complex concentrate against warfarin

Question 14

What score may be used to assess whether a patient with a UGI bleed is a candidate for outpatient management?

Answer 14

Glasgow-Blatchford Bleeding Score (GBS)