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Gastrointestinal (GI) System

Mallory-Weiss syndrome (MWS)

Acute upper gastrointestinal (GI) bleeding due to longitudinal superficial mucosal lacerations (Mallory-Weiss tears).

Acute upper gastrointestinal (GI) bleeding due to longitudinal superficial mucosal lacerations (Mallory-Weiss tears).

  • At squamocolumnar junction at cardia (90%) or lower oesophagus (10%)

History:

Though Albers first reported lower esophageal ulceration in 1833, Kenneth Mallory and Soma Weiss in 1929, more accurately described this condition as lower esophageal lacerations (not ulcerations) happening to patients with repetitive forceful retching and vomiting following excessive alcohol intake.


Etiopathogenesis

Heavy alcohol ingestion:

M/important predisposing factor, accounting for 50-70% cases. Effect of alcohol on the occurrence of bleeding tears in the cardioesophageal area is that it acts as a factor directly or indirectly causing vomiting. In addition, ethyl alcohol affects the esophageal and gastric mucosa by increasing hydrogen ions retrodiffusion, which reduces its protective properties. And thirdly, alcohol intoxication may disrupt the esophageal motor activity and pressure in the lower esophageal sphincter

Other risk factors:

All these conditions involve regurgitation of gastric contents into the esophagus
  • Bulimia nervosa
  • Hyperemesis gravidarum
  • Gastroesophageal reflux disease (GERD)

Longitudinal tear (extending from GE junction to cardia):

Straining of the oesophagus due to vigorous retching, coughing or vomiting causing a vertical split.
  • M/C vessel implicated: Left gastric artery

Presentation

Painless hematemesis (85% cases):

Amount of blood is variable; ranging from blood-streaked mucus to massive bright red bleeding.

Severe bleeding:

  • Melena
  • Dizziness or syncope
  • Dysphagia:If hematoma forms
  • Epigastric pain: Denotes presence of a predisposing factor such as gastroesophageal reflux disease (GERD).

Diagnosis

Clinical suspicion requires confirmation by an upper gastrointestinal endoscopy, which must be performed rapidly after the first hematemesis.

Upper GI endoscopy:

GOLD STANDARD for definitively diagnosing Mallory Weiss tears, and managing simple active esophageal bleeding
  • Longitudinal mucosal tear at esophagogastric junction
Endoscopy of Mallory Weiss Tear
Endoscopy of Mallory Weiss Tear: This 38 year-old male, who had been drinking an average of 20 beers a day for a week, experienced severe hematemesis after about an hour of intense vomiting. He was hospitalized for stabilization and underwent endoscopy showing active bleeding from a gastroesophageal tear. | Dr. Julio Murra-Saca. (2020) Mallory Weiss Syndrome The Gastrointestinalatlas – gastrointestinalatlas.com. Retrieved November 06, 2020, from https://www.gastrointestinalatlas.com/english/mallory_weiss.html

Lab investigations:

  • Complete blood count (CBC)
  • Hemoglobin and hematocrit
  • Coagulation profile (bleeding time, prothrombin time, partial thromboplastin time, and platelet count)
    • Chronic alcoholism results in low platelet count

Management

Conservative management:

Since Mallory-Weiss syndrome is mostly self-limited and recurrence is uncommon, the initial management aims at stabilizing the general condition of the patient, and a conservative approach would be appropriate in most of the patients
  • Proton pump inhibitors (PPIs) & H2 blockers (decrease gastric acidity as increased acidity hinders the recovery of gastric and esophageal mucosa)
  • Antiemetics (control nausea and vomiting)

Endoscopic management:

Patients with active bleeding or signs of recent bleeding at endoscopy need immediate endoscopic treatment for hemostasis.
  • Epinephrine local injection (1:10,000 to 1:20,000 dilution) stops the bleeding through vasoconstriction
  • Multipolar electrocoagulation (MPEC)
  • Sclerosant agent injection
  • Argon plasma coagulation (APC)
  • Endoscopic band ligation (M/efficient procedure for primary hemostasis and for preventing recurrent bleeding)
Status post argon plasma coagulation
Status post argon plasma coagulation | Dr. Julio Murra-Saca. (2020) Mallory Weiss Syndrome The Gastrointestinalatlas – gastrointestinalatlas.com. Retrieved November 06, 2020, from https://www.gastrointestinalatlas.com/english/mallory_weiss.html

Surgical management:

Surgery is rarely necessary and is deemed necessary after the failure of endoscopic procedures or angiotherapy to stop the bleeding.
  • Laparoscopic over-sewing of the tear under endoscopic guidance
  • Sengstaken-Blakemore tube compression (LAST RESORT in debilitated patients)

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