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 80-
90% 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 Male-

to-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 implementing
resuscitative measures as appropriate
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
THANKS

Esophagus, Tear

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Anatomy, esophagus

The original description by Mallory and Weiss in 1929

4) Acute distension of the nondistensible lower

If the shearing forces are high enough, a longitudinal

as can be witnessed during forceful retching at

With conservative therapy, most tears heal

Thus, a MWT can easily be missed if endoscopy is

Sex: Most studies report a male predominance Male-

Age: Patients usually present in their 40s or 50s

although this presentation may be less common than

And hematemesis on first emesis was reported in

Less common presenting symptoms include: melena,

* excessive alcohol use has been reported in 40-75%

Attempt to identify a precipitating factor for the MW

Physical findings relate to the:

Tachycardia, hypotension, orthostatic changes, or overt

Precipitating factors include:

considering the frequency with which patients retch

The reported prevalence is 0.07-0.49%

In one study, 25% of patients had no identifiable

Endoscopy is the procedure of choice for both:

over a mucosal split within or near the

Most patients (>80%) present with a single tear

between 2 and 6 o'clock on endoscopic viewing

performing endoscopy promptly, and triaging patients to:

Five to 35% of patients require some form of

Antiemetic drug therapy (e.g. prochlorperazine)

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