Mallory-Weiss tear

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

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – resuscitation plus supportive care

Plus – consider blood transfusion and management of coagulopathy

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Plus –

consider blood transfusion and management of coagulopathy

Treatment recommended for ALL patients in selected patient group

Blood transfusion (packed red blood cells [RBCs]) may be necessary in certain cases (for ongoing bleeding, or low hemoglobin [Hb] at presentation). Guidelines differ in exact thresholds. The American College of Gastroenterologists (ACG) recommends transfusion for hemodynamically stable patients with upper gastrointestinal (GI) bleeding when Hb <7 g/dL.[39] The ACG guideline also recommends that hypotensive patients may receive transfusion at a higher threshold, and in patients with preexisting cardiovascular disease (CVD), 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 CVD when Hb is <8 g/dL, with a higher threshold for those with CVD.[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] A post-transfusion target of Hb ≥10 g/dL should be aimed for in patients with CVD, while a lower level of Hb 7-9 g/dL is considered appropriate for patients without CVD.[1]

Platelets and coagulation factors should be given in certain circumstances. Patients on antiplatelet treatment should not receive platelet transfusions.[59] The International Consensus Group makes a conditional recommendation based on very low-quality evidence that in patients receiving anticoagulants, endoscopy should not be delayed. The degree of coagulopathy, anticoagulant agent, and patient physiology should be assessed before making therapeutic decisions, and coagulopathy should be treated as necessary, but given the recognized benefits of early endoscopy, it proposes that endoscopy should not be delayed.[40]

The ACG recommend against the use of fresh frozen plasma or vitamin K in patients with acute GI bleeding who are on warfarin.[59] Prothrombin complex concentrate can be considered in patients on warfarin with a life-threatening GI bleed and in those with a supratherapeutic INR substantially exceeding the therapeutic range. Prothrombin complex concentrate can also be considered in patients in whom massive blood transfusion is undesirable because of its effect on coagulopathy or dilution of blood components.[59] Patients on direct oral anticoagulants (DOACs) should not routinely be given prothrombin complex concentrate; those on dabigatran should not routinely receive idarucizumab, and those on rivaroxaban or apixaban should not routinely receive recombinant coagulation factor Xa (andexanet alfa). These recommendations are based on limited evidence of benefit. However, reversal of anticoagulation with these agents may be considered in hospitalized patients with a life-threatening GI bleed who have taken a DOAC within the past 24 hours.[59]

Patients on aspirin for secondary prevention should continue with this; if aspirin is stopped, it should be restarted on the day hemostasis is confirmed endoscopically.[59]

Plus – endoscopy ± intervention

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Plus –

endoscopy ± intervention

Treatment recommended for ALL patients in selected patient group

Esophagogastroduodenoscopy (EGD) is the procedure of choice for diagnosis and treatment in patients with nonvariceal upper gastrointestinal (GI) bleeding.[49][56] It is usually performed after resuscitation, stabilization, and pharmacologic treatment (antiemetic, erythromycin, proton-pump inhibitor [PPI]) is given. It should be performed within 24 hours of upper GI bleeding presentation.[39] The International Consensus Group makes a conditional recommendation based on very low-quality evidence that in patients receiving anticoagulants, endoscopy should not be delayed. The degree of coagulopathy, anticoagulant agent, and patient physiology should be assessed before making therapeutic decisions, and coagulopathy should be treated as necessary, but given the recognized benefits of early endoscopy, it proposes that endoscopy should not be delayed.[40]

High-risk patients should be intubated for airway protection. Early diagnosis is essential to identify and treat high-risk patients (i.e., those with active bleeding [ongoing hematemesis, bright red by nasogastric tube and hematochezia], signs of shock, coagulopathy, age >65 years, or low Hb at presentation, and those with multiple underlying medical problems), thereby allowing more-intensive monitoring and improved outcome.[98] Complete endoscopic exam is recommended because coexisting lesions are commonly associated with Mallory-Weiss tear (MWT).

Several endoscopic modalities are effective for treating high-risk bleeding lesions such as an oozing or an actively bleeding/spurting tear. The choice of methods used will depend on the endoscopist's familiarity, experience, and training, and on equipment availability. Studies have not demonstrated clear superiority of one technique over others.[67][68][69]

Dual therapy is superior to single therapy such as epinephrine (adrenaline) injection.

Different modalities of treatment include: injection therapy with epinephrine in combination with thermal or mechanical therapy; or placement of clips through the endoscope alone or in combination with epinephrine injection. Epinephrine injection stops or reduces the bleeding rate by vasoconstriction and tamponade. It is injected around or into the bleeding point. Sclerosant agents, such as ethanolamine and alcohol, have been described in the literature; however, they are rarely used in practice.[72][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].[Figure caption and citation for the preceding image starts]: Epinephrine (adrenaline) is injected locally around the site of the Mallory-Weiss tearFrom the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].[Figure caption and citation for the preceding image starts]: Mallory-Weiss tear after epinephrine injection (the bleeding has stopped, allowing better visualization of the lesion)From the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].

Through-the-scope clips (TTSCs), alone or in combination with epinephrine injection, can effectively control actively bleeding lesions, and the clips are as effective and safe as other methods.[73][74][75] In the author’s experience, this is the technique of choice in a patient with an actively bleeding tear or laceration. The application of TTSCs and an endoloop in the esophagus has also been described as a method of closure of large MWTs.[76][Figure caption and citation for the preceding image starts]: A through-the-scope clip deployed in the center of the lesion (no previous epinephrine was infused in this case)From the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].[Figure caption and citation for the preceding image starts]: Nonbleeding adherent clotFrom the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].[Figure caption and citation for the preceding image starts]: Three through-the-scope clips deployed to complete closure of the mucosal defectFrom the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].

Over-the-scope clips (OTSC) are available from several vendors and are larger, often permanent clips that have been shown to be effective in treating a wide variety of nonvariceal upper GI bleeding sources, including MWT.[77][78][79]

Various topical hemostatic agents that promote hemostasis have been shown to be a promising rescue therapy, or adjunct to conventional methods for treating upper GI bleeding including MWT.[1][40][80][81][82] They can be administered through the upper endoscope during EGD.[83][84][85]

Thermocoagulation therapy includes multipolar electrocoagulation (MPEC), heater probe, and argon plasma coagulation (APC). Thermocoagulation therapy may be used as a single therapy; however, it is most commonly used in combination with injection therapy. It is often successful and safely given by experienced operators; however, contact thermal therapy should be used with caution when used in the esophagus for a bleeding MWT because of the risk of perforation.[1][86][87] The evidence for APC in this scenario is limited. However, the lack of contact between the catheter and the tissue results in a superficial hemostasis, reducing unwanted tissue damage and perforation, making this technique attractive for certain patients in whom other methods of treatment are not available.[88]

Mallory Weiss tear following cauterization with a bipolar probe

From the personal collection of Douglas Adler; used with permission

Endoscopic band ligation (EBL) has been described in case reports and small controlled trials, but in the experience of this author, is not commonly used for treatment of MWT. The mechanism is similar to that described for variceal band ligation: the affected mucosa is suctioned into the ligating cup device, after which a rubber band is deployed.[89][90][91] For most patients, EBL is used as a single therapy in which the bleeding point is aspirated and ligated. In some unusual cases, in which the bleeding point is not easily localized, EBL has been used as a combination therapy with epinephrine. Epinephrine injection may decrease or slow down the bleeding and help to localize the bleeding point.

Consider – antisecretory therapy pre-endoscopy

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Consider –

antisecretory therapy pre-endoscopy

Treatment recommended for SOME patients in selected patient group

The role of proton pump inhibitors (PPIs) in Mallory-Weiss tear (MWT) is not clear. Guidelines have made conflicting recommendations regarding the administration of PPIs prior to diagnostic esophagogastroduodenoscopy (EGD), when the exact cause of the bleeding remains unclear.[39][40] [ ] 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 early endoscopy cannot be performed, or if contraindications to 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 gastrointestinal bleeding.

PPI treatment started before endoscopy may reduce the need for endoscopic treatment in patients with nonvariceal bleeding.[61] [ ] However, the benefit of using a PPI to prevent rebleeding, and reduce mortality or need for surgery, has not been demonstrated in patients with nonvariceal bleeding.[61][62][63] [ ] In patients with bleeding ulcers, intravenous bolus followed by continuous infusion has been shown to effectively decrease rebleeding in patients who have had successful endoscopic therapy, but these data are difficult to interpret in light of MWT.[64]

If given pre-endoscopy, PPIs are generally administered via the intravenous route. Common PPIs used for actively bleeding lesions include intravenous pantoprazole or esomeprazole. Oral PPI therapy should be considered in those not actively bleeding.[62][63] Oral esomeprazole or rabeprazole can be used.

H2 antagonists can be considered as an alternative therapy to PPIs when PPIs are contraindicated. However, treatment with PPIs achieves more profound and sustained acid suppression than H2 antagonists.[65][66] For actively bleeding lesions, intravenous famotidine can be given followed by oral famotidine. For non-actively bleeding lesions, oral famotidine or cimetidine can be given.

Primary options

pantoprazole: lesions with active bleeding: 80 mg intravenous bolus initially, followed by 8 mg/hour infusion for 72 hours, then 40 mg orally once or twice daily; lesions with no active bleeding: 40 mg orally once or twice daily for 4-8 weeks

esomeprazole: lesions with active bleeding: 80 mg intravenous bolus initially, followed by 40 mg orally/intravenously twice daily; lesions with no active bleeding: 40 mg orally twice daily for 4-8 weeks

rabeprazole: lesions with no active bleeding: 20 mg orally twice daily for 4-8 weeks

Secondary options

famotidine: lesions with no active bleeding: 40 mg orally once daily for 4-8 weeks

cimetidine: lesions with no active bleeding: 400 mg orally twice daily for 4-8 weeks

Consider – antiemetic pre-endoscopy

Consider – erythromycin pre-endoscopy

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Consider –

erythromycin pre-endoscopy

Treatment recommended for SOME patients in selected patient group

Erythromycin is thought to stimulate motilin receptors, with subsequent increase in stomach contraction, which may help to mobilize gastric clots and allow better esophagogastroduodenoscopy (EGD) assessment.[39][50][51][52][53]

In one systematic review conducted by the American College of Gastroenterologists, erythromycin reduced the number of repeat endoscopies, and the length of hospitalizations by at least 1 day.[39]

Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield.[1][40] They may be considered if there is suspected large volume food or blood in the stomach.[60]

Primary options

erythromycin lactobionate: 250 mg intravenously as a single dose 30 minutes before endoscopy

2nd line – surgery or angiography

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2nd line –

surgery or angiography

Surgery should be reserved for situations where endoscopic hemostasis of bleeding has failed or transmural esophageal perforation is a problem.[56] Laparoscopic oversewing of the laceration at the gastroesophageal junction can be readily performed under video control with endoscopic guidance with excellent results.[92]

Angiography is indicated for massive bleeding when esophagogastroduodenoscopy (EGD) and surgery are not readily available, or when patients have an absolute contraindication to surgery or endoscopy therapy.[93] Angiography can involve either of the following methods:

Infusion of a vasoconstrictor agent such as vasopressin into the superior mesenteric artery or left gastric artery, or by direct infusion into a vessel that leads to a bleeding artery.[95]

Transcatheter embolization with an artificial material, such as gelfoam, or less often with the patient's own clotted blood.[96][97]

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Mallory-Weiss tear

all patients

resuscitation plus supportive care

consider blood transfusion and management of coagulopathy

endoscopy ± intervention

antisecretory therapy pre-endoscopy

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

antiemetic pre-endoscopy

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

erythromycin pre-endoscopy

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

surgery or angiography

Mallory-Weiss tear

Treatment algorithm

all patients

resuscitation plus supportive care

consider blood transfusion and management of coagulopathy

endoscopy ± intervention

antisecretory therapy pre-endoscopy

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

antiemetic pre-endoscopy

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

erythromycin pre-endoscopy

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

surgery or angiography