Mallory-Weiss tear

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Key Recommendations

Patients with nonvariceal upper gastrointestinal (GI) bleeding should undergo stabilization, resuscitation, risk assessment, and pre-endoscopic care before endoscopic evaluation.[37][38]

Urgent consideration

Patients who are actively bleeding with multiple medical comorbidities should be attended to quickly. The initial diagnostic evaluation involves an assessment of hemodynamic stability and resuscitation if necessary; the ABC (airway, breathing, and circulation) approach should be implemented with appropriate resuscitation and stabilization, including crystalloid fluids to maintain adequate blood pressure. Patients in shock should be managed in a critical care setting wherever possible.

Patients with ongoing blood loss (hematemesis, hematochezia, or melena) or suspected of having cardiac ischemia should be considered for packed red blood cells (PRBC) transfusion. Guidelines differ in exact thresholds.

The American College of Gastroenterologists recommends transfusion for hemodynamically stable patients with upper GI bleeding when hemoglobin (Hb) <7 g/dL.[39] Hypotensive patients may receive transfusion at a higher threshold, and in patients with preexisting cardiovascular disease, transfusion is reasonable when Hb <8 g/dL. Patients with acute coronary syndrome may be considered for transfusion when Hb >8 g/dL, but the guidelines note that this is based on very limited evidence.[39]
The International Consensus Group suggests transfusion for patients with acute upper GI bleeding without cardiovascular disease when Hb is <8 g/dL, with a higher threshold for those with cardiovascular disease.[40]
Similarly, although it does not specify ranges, the American College of Chest Physicians recommends a restrictive transfusion strategy over a permissive transfusion strategy in critically ill patients, notably including those with acute GI bleeding, but in critically ill patients with acute coronary syndrome it suggests against a restrictive transfusion strategy.[41]

[Figure caption and citation for the preceding image starts]: Actively bleeding tear appears as a red longitudinal defect with normal surrounding mucosaFrom the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].

For more information on managing patients with massive hemorrhage, see Shock.

For patients presenting with chest pain, see Evaluation of chest pain.

History

A complete medical history should be taken to establish any causative factors and conditions associated with Mallory-Weiss tear (MWT). However, in >40% of patients with MWT, no precipitating factor is found.[14]

History should include:

Previous history of hematemesis or confirmed MWT
Drugs and alcohol intake, particularly use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), anticoagulants, and antiplatelet agents, and amount of daily alcohol intake
Concurrent medical problems: history of liver disease, peptic ulcer disease, esophageal reflux/heartburn, hiatal hernia, dysphagia, odynophagia, weight loss, or abdominal aortic aneurysm
Any previous surgical interventions such as abdominal aortic vascular graft, gastric bypass surgery, or prior surgical or endoscopic fundoplication

Clinical presentation

The classic presentation of MWT consists of a small and self-limited episode of hematemesis (that varies from flecks or streaks of blood mixed with gastric contents and/or mucus, blackish or "coffee grounds", to a frank bright-red bloody emesis), typically occurring after a bout of retching, vomiting, coughing, straining, or blunt trauma, or any other factors that increase pressure at the level of the gastroesophageal junction.[1]

However, the classic history is not always obtained. One study reported blood on the first emesis in only 50% of patients.[14] Massive hemorrhage requiring urgent assessment and blood transfusion and even leading to death has been described, but is less common among patients with MWT than other causes of upper GI bleeds.[1][3][4]

Less common presenting symptoms include light-headedness, dizziness, syncope, dysphagia, odynophagia, melena, hematochezia, retrosternal pain with interscapular radiation, and midepigastric abdominal pain. A high index of suspicion is imperative.

Physical exam

In general, a complete physical exam, including an inspection of the nostrils and oropharynx, and a rectal evaluation, should be performed. There are no specific physical signs in patients with MWT. The physical findings are linked to the underlying disorder causing the vomiting, retching, coughing, and/or straining.

Orthostatic changes in blood pressure (BP) should be checked at this point if not performed at presentation. Other physical findings, when present, are related to the rate and the degree of blood loss. Such signs and symptoms include tachycardia, orthostatic BP changes, hypotension, dizziness, light-headedness, and, less commonly, shock.

Initial laboratory investigation

Complete blood count, Hb, hematocrit, platelets, blood urea nitrogen (BUN), creatinine, and electrolytes are important to evaluate the severity of the bleeding, make a risk assessment, and monitor patients. Liver function tests should be part of the initial blood work in patients with upper GI bleeding as they can rule out liver disease, which may predispose a patient to esophageal varices, gastric varices, or portal hypertensive gastropathy as potential sources of bleeding.

Blood type and antibodies should be obtained for potential blood transfusion. Prothrombin time (PT) and activated partial thromboplastin time (PTT) are needed in all patients on anticoagulants or those suspected of coagulopathy (e.g., liver pathology, lupus).

Risk assessment

Several risk scoring systems have been developed and validated, but each has been shown to perform most accurately to predict particular outcomes: for example, mortality, risk of rebleeding, need for transfusion, or the need for surgical or endoscopic therapy. In summary, the major international, American, and European upper GI bleeding guidelines only suggest the Glasgow-Blatchford bleeding score (GBS) to identify, with high certainty, very low-risk patients who can be safely managed with outpatient esophagogastroduodenoscopy (EGD).[39][40][42] The GBS (pre-endoscopy score) is calculated using the following parameters: BUN, Hb, systolic blood pressure, pulse, melena, syncope, liver disease, and cardiac failure.[38][43][44] Patients with a score of 0-1 are classified as very low risk, which indicates a ≤1% false negative rate for requiring in-hospital interventions or death.[39][40][42] Patients with a score of ≥2 should be admitted promptly and receive an EGD within 24 hours.[1][39] [ Blatchford score for gastrointestinal bleeding Opens in new window ]

Other initial investigations to consider

EGD is the first-line diagnostic and therapeutic investigation once patients are deemed acceptable candidates for the procedure.[45] Absolute contraindications for an upper EGD include severe hypotension/shock, acute perforation, acute myocardial infarction, and peritonitis. Relative contraindications for an upper EGD include an uncooperative patient, coma (except those already intubated), cardiac arrhythmias, or myocardial ischemia (recent event).

EGD should be performed for patients admitted with suspected nonvariceal upper GI bleeding within 24 hours of upper GI bleeding presentation.[39][40][42] Protection of the airway with intubation should be considered depending on the clinical condition of the patient.

EGD may identify a tear, usually at or below the gastroesophageal junction on the lesser curvature (between 2 and 6 o'clock). The tear is usually a single linear defect, which may vary in length from a few millimeters to several centimeters, with normal surrounding mucosa. In rare cases there may be more than one tear. Coexisting lesions are common and may contribute to the bleeding process (e.g., peptic ulcer, erosive esophagitis).

For more information on what investigations might be helpful in managing patients with massive hemorrhage, see Shock.

For patients presenting with chest pain, see Evaluation of chest pain.

Imaging

Early diagnosis may allow the identification of high-risk lesions such as actively bleeding lesions. Treatment of these lesions may allow more intensive monitoring and may reduce the likelihood of an adverse outcome.

Bleeding Mallory Weiss tear

From the personal collection of Douglas Adler; used with permission

A laceration or tear is not visible with conventional radiography in the absence of a full thickness perforation; however, chest x-ray may be useful as an initial assessment for unstable patients to rule out additional chest pathology or for those suspected of having a complication such as perforation.[35] If perforation rather than tear is suspected due to subcutaneous emphysema or crepitus, a contrast study or a computed tomography (CT) chest is indicated to confirm and localize the level of perforation.[46]

Either visceral angiography, or CT angiography of the abdomen and pelvis without and with intravenous contrast, is indicated in patients where there is an actively bleeding lesion and endoscopy is unavailable, or has failed to control the bleeding.[45][47] Where endoscopy confirms nonvariceal upper GI bleeding but cannot clearly identify the bleeding site, CT angiography of the abdomen and pelvis without and with intravenous contrast is indicated.[45]

The source of bleeding may be demonstrated on a selective cannulation of the left gastric artery. A linear collection of contrast will be seen in patients with tear or laceration at or near to the gastroesophageal junction.

Pre-endoscopy care

Guidelines have made conflicting recommendations regarding pre-endoscopy proton-pump inhibitors (PPIs).[39][40][48] [ ] Given the lack of certainty around the data, it is suggested that local protocols are followed. Some experts still suggest pre-endoscopy PPIs to downgrade any high-risk lesions particularly when endoscopy cannot be performed, or if contraindications to early (within 24 hours) endoscopic evaluation exist.[49] In the experience of this author, the benefits of giving PPIs prior to endoscopy outweigh potential harms and PPIs are widely administered for nonvariceal upper GI bleeding.

Administration of intravenous erythromycin 30 minutes before endoscopy is thought to stimulate motilin receptors, with a subsequent increase in stomach contraction that may help to mobilize gastric clots. This may allow better endoscopic assessment and reduce the need for repeat endoscopy.[1][39][50][51][52][53]

An antiemetic is useful for controlling nausea and vomiting, which may be a cause or an aggravating factor in patients with MWT, and is administered pre-endoscopy, if needed.

Use of this content is subject to our disclaimer