Esophagus, Tear

Anatomy, esophagus

Esophagus, Tear Mallory-Weiss tear Mallory-Weiss syndrome is characterized by upper gastrointestinal bleeding secondary to longitudinal mucosal lacerations at the: * gastroesophageal junction or gastric cardia The original description by Mallory and Weiss in 1929 1) Involved patients with persistent: retching and vomiting following an alcoholic binge

Esophagus, Tear Mallory-Weiss tear Typically video endoscopic Illustration

Esophagus, Tear Mallory-Weiss tear 2) However, Mallory-Weiss syndrome may occur after any event that provokes a sudden rise in:

* intragastric pressure or * gastric prolapse into the esophagus

Esophagus, Tear Mallory-Weiss tear Pathophysiology:

3) A Mallory-Weiss tear (MWT) likely occurs as a result of:

* a large * rapidly occurring and * transient transmural pressure gradient across the region of the gastroesophageal junction

Esophagus, Tear Mallory-Weiss tear Pathophysiology: 4) Acute distension of the nondistensible lower esophagus can also produce a linear tear in this region

Mallory-Weiss tear Pathophysiology: 5) Hiatal hernia With a rapid rise in intragastric pressure due to precipitating factors, such as: retching or vomiting the transmural pressure gradient increases dramatically across the hiatal hernia If the shearing forces are high enough, a longitudinal laceration eventually occurs

Esophagus, Tear Mallory-Weiss tear Pathophysiology: Within the hernia, the tear is more likely to involve the lesser curvature of the gastric cardia, which is relatively immobile compared to the remainder of the stomach

Esophagus, Tear Mallory-Weiss tear Pathophysiology: 6) Another potential mechanism for MWTs is the violent prolapse or intussusception of the upper stomach into the esophagus as can be witnessed during forceful retching at endoscopy

Esophagus, Tear Mallory-Weiss tear Frequency: MWTs account for 1-15% of cases of upper gastrointestinal bleeding

Esophagus, Tear Mallory-Weiss tear Mortality/Morbidity: Bleeding from MWTs stops spontaneously in 8090% of patients With conservative therapy, most tears heal uneventfully within 48 hours Thus, a MWT can easily be missed if endoscopy is delayed

Esophagus, Tear Mallory-Weiss tear Mortality/Morbidity Current clinical experience suggests a significantly lower mortality rate from MWTs Sex: Most studies report a male predominance Maleto-female ratios reportedly are 2-4:1 Age: Patients usually present in their 40s or 50s But the age range is quite wide

Esophagus, Tear Mallory-Weiss tear

Clinical Presentation History The classic presentation consists of an episode of hematemesis following a bout of: retching or vomiting although this presentation may be less common than previously thought

Esophagus, Tear Mallory-Weiss tear

Clinical Presentation History Previous studies found that a typical history was obtained in only about 30% of patients And hematemesis on first emesis was reported in 50% of patients

Clinical Presentation (Mallory-Weiss tear) History Hematemesis is present in 85% of patients Less common presenting symptoms include: melena, hematochezia, syncope, and abdominal pain * excessive alcohol use has been reported in 40-75% of patients, and * aspirin use in up to 30% Attempt to identify a precipitating factor for the MW

Esophagus, Tear Mallory-Weiss tear Physical Examination MWTs do not elicit specific physical signs Physical findings relate to the:

* rate and * degree of gastrointestinal blood loss Tachycardia, hypotension, orthostatic changes, or overt shock may be evident

Esophagus, Tear Mallory-Weiss tear Causes: The presence of a hiatal hernia is a predisposing factor and is found in 35-100% of patients with MWTs Precipitating factors include: * retching * hiccuping * vomiting * coughing * straining * primal scream therapy * blunt abdominal trauma and * cardiopulmonary resuscitation

Esophagus, Tear Mallory-Weiss tear Causes: Iatrogenic tears are uncommon considering the frequency with which patients retch during endoscopy The reported prevalence is 0.07-0.49%

Esophagus, Tear Mallory-Weiss tear Causes: In a few cases, no apparent precipitating factor can be identified In one study, 25% of patients had no identifiable risk factor

Esophagus, Tear Mallory-Weiss tear

Differential Diagnosis Boerhaave Syndrome Esophagitis Gastric Ulcers

Esophagus, Tear Mallory-Weiss tear Diagnosis Workup Lab Studies * hemoglobin and * hematocrit studies are performed to assess the: * severity of the initial bleeding episode and * to monitor patients

Mallory-Weiss tear Diagnosis Workup Lab Studies * platelet count * prothrombin time and * activated partial thromboplastin time are performed to assess for severe: * thrombocytopenia and * coagulopathy

Mallory-Weiss tear Diagnosis Workup Lab Studies * BUN * creatinine and * electrolyte levels are measured to guide intravenous fluid therapy

Mallory-Weiss tear Diagnosis Workup Lab Studies * Blood type and * antibody screen are obtained for potential blood transfusions

Mallory-Weiss tear Diagnosis Workup Imaging Studies * Barium or * Gastrografin studies should not be performed owing to their:

* low diagnostic sensitivity and * interference with endoscopic assessment and therapy

Mallory-Weiss tear Diagnosis Workup Other Tests

ECG To assess for myocardial ischemia related to acute gastrointestinal blood loss, especially in patients with significant: * anemia * hemodynamic instability * cardiovascular disease * coexisting chest pain, and/or * advanced age

Mallory-Weiss tear Procedures Perform endoscopy early in the clinical course Endoscopy is the procedure of choice for both: diagnosis and therapy

Mallory-Weiss tear Procedures Endoscopic diagnosis of a MWT is readily made by identifying:

* active bleeding * an adherent clot or * a fibrin crust over a mucosal split within or near the gastroesophageal junction

Mallory-Weiss tear Procedures On average, the split is: 2-3 cm in length and a few millimeters in width Most patients (>80%) present with a single tear

Mallory-Weiss tear Procedures The usual location of the tear is just below the gastroesophageal junction on the lesser curvature of the stomach between 2 and 6 o'clock on endoscopic viewing with the patient in the left lateral decubitus position

Mallory-Weiss tear Treatment

Medical Care: Initial management consists of resuscitative measures as appropriate

implementing

performing endoscopy promptly, and triaging patients to: a) intensive care, b) hospital inpatient, or c) outpatient management, depending on the severity of: * bleeding * comorbidities and * risk of rebleeding and complications

Mallory-Weiss tear Treatment

Medical Care: Most patients have stopped bleeding at the time of endoscopy Five to 35% of patients require some form of intervention, mostly endoscopic

Mallory-Weiss tear Treatment

Medical Care: Otherwise, supportive care with volume and/or blood replacement, acid suppression (e.g. omeprazole) Antiemetic drug therapy (e.g. prochlorperazine) is sufficient in most patients presenting with a MWT

Mallory-Weiss tear Treatment

Surgical Care: Surgical oversewing of the tear is reserved for the occasional bleeding case refractory to: 1) endoscopic therapy or 2) angiotherapy

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