mallory-weiss tear Flashcards
definition of mallory-weiss tear
persistent vomiting/retching causes haematemesis via an oesophageal tear
characterised by a tear or laceration often along the R border of, or near the gastro-oesophageal junction
aetiology of mallory-weiss tear
pathogenesis not completely understood
after event that causes sudden rise in the pressure gradient across the gastro-oesophageal junction eg retching, vomiting, coughing, straining, hiccups, closed-chest pressure or cardiopulmonary resuscitation, acute abdominal blunt trauma, primal scream therapy, alcohol, medications (aspirin or other non-steroidal anti-inflammatory drugs [NSAIDs]), chemotherapeutic agents, and oesophageal instrumentation
RF for MW tear
condition predisposing to retching, vomiting, and/or straining
retching during endoscopy or other instrumentation
hiatal hernia
chronic cough
significant alcohol use
previous instrumentation - endoscopy. Usually when female, elderly and hiatal hernias.
conditions that cause increased vomiting
GI
- food poisening
- infectious gastroenteritis
- peptic ulcer disease
- malrotation
- intussusception
- volvulus
- gastric outlet obstruction
- gastroparesis
- hepatobiliary
- hepatitis
- gallstones
- cholecystitis
- hyperemesis gravidarum
renal disease
- UTI
- nephrolithiasis
- renal failure
- ureteropelvic obstruction
neurological disease
- tumours
- hydrocephalus
- congenital disease
- trauma
- meningitis
- pseudotumour cerebri
- migraine headaches
- seizures
pschiatric disease
- anorexia nervosa
- bulimia
- cyclic vomiting syndrome
toxins, polyethylene glycol lavage (bowel preparation for colonoscopy), chemotherapy agents (e.g., cisplatin), and post-anaesthesia or post-surgery.
causes of chronic cough
whooping cough,
bronchitis,
bronchiectasis,
emphysema,
chronic obstructive pulmonary disease
lung cancer.
epidemiology of MW tear
represents 3% to 15% of cases of upper GI bleeding
less common in children, representing about 0.3% of upper GI bleeds
men>women
30-50yrs
sx of MW tear
vomit a couple of times and then blood in the vomit (haematemesis) - varies from flecks or streaks of blood mixed with gastric contents and/or mucus, blackish or ‘coffee ground’, to a bright-red bloody emesis after raised pressure at junction
lightheadedness/dizziness from sudden drop in BP from bleeding
postural/orthostatic hypotension
dysphagia
odynophagia
pain
melaena
haematochezia
signs of MW tear
shock
signs of anaemia - pallor, tachycardia, dyspnoea, and fatigue.
Ix for MW tear
FBC
- Blood should be transfused when Hb is <8 g/dL or <100 g/L (<10 g/dL) in patients with CAD or multiple comorbidities.
- Hb, Hct, and platelets (plt) are usually unremarkable in an acute setting; however, anaemia may range from mild to severe in rare cases
urea - high if ongoing bleeding
LFT - rule out liver disease which may predispose a patient to oesophageal varices, gastric varices, or portal hypertensive gastropathy as potential sources of bleeding.
PT/INR
- typically normal
- prolonged - anticoagulation therapy, liver pathology, lupus, and other coagulopathies.
PTT - typically normal
CXR
- typically normal in uncomplicated MWT
- initial test diagnosis in patients with suspected oesophageal perforation.
oesophagogastroduodenoscopy
- A tear or laceration typically appears as a red longitudinal defect with normal surrounding mucosa
- the lesions vary from a few millimetres to several centimetres.
cross matching/blood grouping
Mx of MWT
control bleeding, prevent complication, eliminate the underlying cause
resus
- Bilateral, peripheral, or central intravenous access is important to maintain adequate fluid replacement (crystalloids)
- Blood transfusion (packed red blood cells) may be necessary in certain cases
- Platelets and coagulation factors should be given in certain circumstances.
A nasogastric or orogastric tube could be placed carefully in patients with ongoing bleeding or those suspected of having concomitant upper gastrointestinal (GI) bleeding sources, such as peptic ulcer disease, oesophageal varices, and Dieulafoy’s lesions.
- This will decompress the stomach and allow gastric lavage.
intravenous proton-pump inhibitor (PPI) is warranted in all patients with ongoing upper GI bleeding severe enough to require endoscopic evaluation.
Elective endotracheal intubation should be considered in patients with ongoing haematemesis or altered respiratory or mental status. Elective endotracheal intubation will protect the airway and facilitate endoscopy. Conventional radiography of the chest should be obtained to rule out perforation or underlying pulmonary pathology. It is important to look for mediastinal or free peritoneal air.
correct electrolyte abnormalities
fresh frozen plasma
anti-emetic
endoscopy mx for MWT
1st line
after medical treatment
dual therapy is superior to single therapy such as adrenaline injection - do injection therapy and thermal/mechanical eg haemoclip placement
endoscopic band ligation
Complete endoscopic examination is recommended because co-existing lesions are commonly associated with MWT.
surgery mx for MWT
rarely needed - endoscopic haemostasis of bleeding has failed or transmural oesophageal perforation has occurred.
Laparoscopic over-sewing of the laceration at the gastro-oesophageal junction
Angiography is indicated for massive bleeding when oesophagogastroduodenoscopy and surgery are not readily available or when patients have an absolute contraindication for surgery or endoscopic therapy
Compression by Sengstaken-Blakemore tube is a last resort and has been used in the medically debilitated patient
complications of MWT
- vasopressin infusion related abdominal pain
- re-bleeding
- myocardial ischemia or infarction
- adrenaline related hypertensive emergency
- hypovolaemic shock/death
- oesophageal perforatoon
- gastric ischemia or infarct
- metabolic disturbance
Px for MWT
for most people the bleeding is self-limited - stopped by time of endoscopy
excellent in pt w/o complications/associated disease
Re-bleeding occurs in about 8% to 15% of patients. It usually occurs within the first 24 hours and most often in patients with high-risk factors for re-bleeding
