Mallory-Weiss tear

For most patients, bleeding is self-limiting, and will have stopped by the time of endoscopy.[2]Holster IL, Kuipers EJ. Management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives. World J Gastroenterol. 2012 Mar 21;18(11):1202-7. https://pmc.ncbi.nlm.nih.gov/articles/PMC3309909 http://www.ncbi.nlm.nih.gov/pubmed/22468083?tool=bestpractice.com ​ Prognosis is excellent in patients without associated disease or complications.

The Rockall post-endoscopy score

The National Institute for Health and Care Excellence (NICE) in the UK recommends carrying out a full Rockall score post-endoscopy.[36]National Institute for Health and Care Excellence. Acute upper gastrointestinal bleeding in over 16s: management. August 2016 [internet publication]. https://www.nice.org.uk/guidance/cg141 [ Rockall Score for Upper Gastrointestinal Bleeding Opens in new window ] ​​ A score of ≤2 is associated with a low risk of further bleeding or death.

The score includes clinical criteria (increasing age, presence of comorbidities, shock) as well as endoscopic findings (such as source of bleeding and/or stigmata of recent bleeding) to identify patients at risk of adverse outcome after acute upper GI bleeding.[39]Laursen SB, Dalton HR, Murray IA, et al. Performance of new thresholds of the Glasgow Blatchford score in managing patients with upper gastrointestinal bleeding. Clin Gastroenterol Hepatol. 2015 Jan;13(1):115-21. http://www.ncbi.nlm.nih.gov/pubmed/25058843?tool=bestpractice.com [45]Alexandrino G, Domingues TD, Carvalho R, et al. Endoscopy timing in patients with acute upper gastrointestinal bleeding. Clin Endosc. 2019 Jan;52(1):47-52. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC6370919 http://www.ncbi.nlm.nih.gov/pubmed/30300984?tool=bestpractice.com ​ The total score is calculated by simple addition. A score of <3 carries a good prognosis, but a total score of 8 or higher carries a high risk of mortality. The Rockall score has been shown to be more accurate in predicting mortality (with an optimal cut-off of ≥5 for post-endoscopy Rockall) than the risk of rebleeding.[66]Roberts I, Shakur-Still H, Afolabi A, et al. A high-dose 24-hour tranexamic acid infusion for the treatment of significant gastrointestinal bleeding: HALT-IT RCT. Health Technol Assess. 2021 Oct;25(58):1-86. http://www.ncbi.nlm.nih.gov/pubmed/34663491?tool=bestpractice.com [85]Alali AA, Barkun AN. An update on the management of non-variceal upper gastrointestinal bleeding. Gastroenterol Rep (Oxf). 2023;11:goad011. https://pmc.ncbi.nlm.nih.gov/articles/PMC10027415 http://www.ncbi.nlm.nih.gov/pubmed/36949934?tool=bestpractice.com

NICE recommends a repeat endoscopy, with treatment as appropriate, for all patients at high risk of rebleeding, particularly if there is doubt about adequate haemostasis at the first endoscopy.[36]National Institute for Health and Care Excellence. Acute upper gastrointestinal bleeding in over 16s: management. August 2016 [internet publication]. https://www.nice.org.uk/guidance/cg141

Rebleeding 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 ing, including:[84]Bharucha AE, Goustout CJ, Balm RK. Clinical and endoscopic risk factors in the Mallory-Weiss syndrome. Am J Gastroenterol. 1997 May;92(5):805-8. http://www.ncbi.nlm.nih.gov/pubmed/9149189?tool=bestpractice.com

• Age (>65 years)

• Haematemesis and/or haematochezia at presentation

• Haemodynamic instability/shock

• Alcohol-use disorder

• Aspirin/non-steroidal anti-inflammatory drug use

• Multiple blood transfusions

• Comorbidities (anaemia, chronic liver disease, coronary artery disease, COPD, renal failure)

• Actively bleeding lesions.

Patients with high risk factors require more intense monitoring and should continue to be evaluated in hospital for at least 48 hours.

Patients with no risk factors for rebleeding should be observed in hospital and discharged.