Mallory-Weiss tear - Upper GI

Question 1

What is a Mallory-Weiss tear?

Answer 1

Mallory-Weiss tear (MWT), also known as Mallory-Weiss syndrome (MWS)

• is characterised by a tear or laceration often along the right border of, or near, the gastro-oesophageal junction.

​

• Pts present with non-variceal upper GI bleeding.
• The haemorrhage is usually self-limited
  
  • ceasing spontaneously in 80% - 90% of cases

Question 2

What are oesophageal varices?

Answer 2

extremely dilated sub-mucosal veins in 1/3 of oesophagus.

• Most common cause:
  
  • portal hypertension (due to cirrhosis)
• people with esophageal varices have a strong tendency to develop severe bleeding which left untreated can be fatal.
• definitive investigation: OGD

Question 3

What % of pts with a GI bleed do Mallory-Weiss tears account for?

Answer 3

3% to 15%

Question 4

What is the aetiology of a Mallory-Weiss tear?

Answer 4

Factors such as

• coughing
• retching
• vomiting
• 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
• oesophageal instrumentation

Hiatal hernia, which is present in 40% to 100% of people with MWT, is considered by many to be a precipitating factor, –> an oesophageal tear to occur.

However, in >40% of patients an identifiable risk factor is not found

Question 5

1. Name some conditions that may induce vomiting
2. Name some conditions that are associated with a chronic cough

Answer 5

Question 6

Summarise the pathogenesis of a Mallory-Weiss tear

Answer 6

• The pathogenesis of MWT is not completely understood.
• However, most cases seem to occur as a result of a sudden rise in abdominal pressure or transmural pressure gradient across the gastro-oesophageal junction with a corresponding low intrathoracic pressure.
• When these forces are high enough to cause distention in this poorly distended area, an acute gastro-oesophageal tear or laceration may occur.

Question 7

What are the classifications of a Mallory-Weiss tear?

Answer 7

Question 8

Name the risk factors for a Mallory-Weiss tear

Answer 8

• conditions predisposing to retching, vomiting, and/or straining
• chronic cough
• hiatus hernia
• significant alcohol use
• retching during endoscopy or other instrumentation
• previous instrumentation

weak:

see image

Question 9

Summarise the epidemiology for a Mallory-Weiss tear

Answer 9

• Admission to hospital for non-variceal upper gastrointestinal (GI) bleeding is common, with an incidence of about 50 to 150 per 100,000 people per year.
• Mortality ranges between 8% and 14%.
• MWT represents 3% to 15% of cases of upper GI bleeding, or 5 to 12 bleeding episodes of upper GI per 100,000 people.
• It is less common in children, representing about 0.3% of upper GI bleeds.
• MWT is more common in men than in women in a ratio of 3:1
  
  • childbearing age women, cause is commonly: hyperemesis gravidarum
• age of presentation may vary but is most common in people aged between 30 and 50 years

Question 10

What are the presenting symptoms for a Mallory-Weiss tear?

Answer 10

• haematemesis after an episode of
  
  • forceful or recurrent retching
  • vomiting
  • coughing
  • straining
• pain - rare
  
  • possible differential: Boerhaave’s syndrome (spontaneous rupture of the oesophagus)
• dysphagia - rare
• odnophagia (due to possible tear in oesophagus) - rare
• malaena - rare
  
  • Usually associated with upper GI bleeding proximal to ligament of Treitz
• Hematochezia - rare
  
  • = ​passage of fresh blood from the anus
• light-headedness/dizziness
• postural/orthostatic hypotension
• shock - rare
• signs of anaemia - rare in acute presentation

Question 11

Describe the haematemesis that occurs during a Mallory-Weiss tear.

Answer 11

small and self-limited episode

after an episode of retching, vomiting, coughing, straining, or blunt trauma:

• flecks or streaks of blood mixed with gastric contents and/or mucus,
• blackish or ‘coffee ground’
• to a bright-red bloody emesis

Question 12

1. What are the red flags symptoms for urgent Tx in ?mallory-weiss tear ?
2. What are the red flags for malignancy when suspecting mallory-weiss tear?

Answer 12

1. Hematochezia, shock
2. dysphagia (in at risk older pts)

Question 13

What are the signs of anaemia?

Answer 13

• pallor
• tachycardia
• dyspnoea
• fatigue

Question 14

What are the confounding factors for malaena?

Answer 14

• bismuth-containing products (e.g., Pepto-Bismol)
• iron supplements

Question 15

What are the signs of Mallory-Weiss tear O/E?

Answer 15

• obs: postural hypotension
• Melaena

usually none (see symptoms)

Question 16

What are the other possible differentials to be considered in a case where a Mallory-Weiss tear is suspected?

Answer 16

Question 17

What are the primary investigations for a ?Mallory-Weiss tear?

Answer 17

bloods:

• FBC
  
  • ​usually unremarkable in acute setting, but anaemia can present from mild to severe
• urea
  
  • high in patient with ongoing bleeding (as bleeding –> renal perfusion drops –> renal function falls)
• LFTs
  
  • typically normal, except in a patient with underlying or co-existing liver disease
  • used to exclude liver disease which then predisposes pts to oesophageal varices, gastric varices, or portal hypertensive gastropathy as potential sources of bleeding
• PT/INR
  
  • typically normal
  • but can be abnormal, suggesting possible liver pathology
• cross-matching/blood grouping
  
  • ​in case blood transfusion is required

imaging

• CXR
  
  • typically normal in uncomplicated MWT
  • Laceration or tear is not visible under conventional radiography; may be an initial test diagnosis in patients with suspected oesophageal perforation.
• oesophagogastroduodenoscopy (OGD) (= definitive)
  
  • 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.

Question 18

What are some possible secondary investigations for a ?Mallory-Weiss tear?

Answer 18

Bloods

• creatinine kinase
  
  • Should be considered in patients with a history of CAD, symptoms of cardiac ischaemia, massive bleeding, or multiple comorbidities
  • should be normal in MWT
• creatinine kinase-MB
  
  • Should be considered in patients with a history CAD, symptoms of cardiac ischaemia, massive bleeding, or multiple comorbidities.
  • should be normal in MWT
• troponin
  
  • Should be considered in patients with a history of CAD, symptoms of cardiac ischaemia, massive bleeding, or multiple comorbidities
  • should be normal in MWT

Imaging

• ECG
  
  • ​see above
• angiography
  
  • ​indicated for massive haemorrhages in which visualisation of the lesion is not possible, when endoscopic evaluation is not readily available, or when OGD evaluation is contraindicated

Question 19

What are the main goals of Tx of a Mallory-Weiss tear?

Answer 19

main goals of initial treatment is to

1. control the bleeding,
2. prevent any complication relating to it,
3. eliminate the underlying cause whenever possible
4. identify patients at risk of re-bleeding or those who will need admission to the hospital for further treatment

Question 20

Explain the management plan for a Mallory-Weiss tear

Answer 20

• MWT is mostly self limiting, so Tx = generally supportive.
• Emergency treatment is reserved for patients showing signs or symptoms of instability & those with multiple co-morbidities

resuscititation

• fluids, ?bloods, ?platelets, ?coagulation factors
• OG/NG tube in those w concomitant upper gastrointestinal (GI) bleeding sources, such as peptic ulcer disease, oesophageal varices, and Dieulafoy’s lesions –> decompresses stomach + allows gastric lavage
• Elective ET tube in patients with ongoing haematemesis or altered respiratory or mental status
• CXR - to rule out perforation or underlying pulmonary pathology. It is important to look for mediastinal or free peritoneal air.
• anti-emetic

1st-line Tx in an actively bleeding patient:

• therapeutic endoscopy
  
  • ​most sensitive & specific test for MWT & can exclude other causes ofo GI bleeding
  • before: anti-secretory drug therapy with PPIs or H2 antagonists / anti-emetic

later Tx - RARE

• angiography with embolisation of the arteries supplying region / surgical repair
  
  • ~ be required to control bleeding

last resort:

• Sengstaken-Blakemore tube –> compression

Question 21

Explain the therapeutic endoscopy options available

Answer 21

• Injection therapy (adrenaline)
• Haemoclip placement
• Thermocoagulation therapy
• Endoscopic band ligation (EBL)

Question 22

Why might a vasopressin infusion be administered to pts with a Mallory-Weiss tear?

Question 23

What are the possible complications of a Mallory-Weiss tear?

Answer 23

Question 24

Summarise the prognosis of a Mallory-Weiss tear

Answer 24

• For most patients, bleeding is self-limited, and will have stopped by the time of endoscopy.
• Prognosis is excellent in patients without associated disease or complications.
• A routine second endoscopic evaluation is not recommended unless the patient remains symptomatic after initial treatment.

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.
• High-risk factors for re-bleeding include:
  
  • old age (aged >65 years)
  • haematemesis and/or haematochezia at presentation,
  • haemodynamic instability/shock
  • alcoholism
  • aspirin/NSAID use
  • those with multiple blood transfusions
  • comorbidities (anaemia, chronic liver disease, CAD, COPD, renal failure),
  • those with actively bleeding lesions