History and exam
Key diagnostic factors
common
hematemesis
The classic presentation of Mallory-Weiss tear (MWT) consists of a small and self-limited episode of hematemesis (flecks or streaks of blood mixed with gastric contents and/or mucus, blackish or "coffee grounds") 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] Patients may also present with a frank bright-red bloody emesis.
However, this classic presentation occurs in only 29% of patients.[54] Another study reported blood on the first emesis in only 50% of patients.[14] A high index of suspicion is imperative in these circumstances. Massive hemorrhage requiring blood transfusion and even leading to death has been described, but it is extremely rare in MWT.[3][4][54]
Other diagnostic factors
common
light-headedness/dizziness
Can be due to a sudden drop in blood pressure caused by bleeding.
postural/orthostatic hypotension
Seen in up to 45% of adults with Mallory-Weiss tear.[14]
uncommon
dysphagia
Considered an alarming symptom in patients over the age of 50 with a new onset of dysphagia, in those who smoke and drink alcohol on a regular basis, in those with a long history of esophageal reflux, and when it is progressive (for solid food first, then solid and liquids) in a short period of time (weeks or month). These patients need an immediate evaluation to determine the exact cause (which may be an upper gastrointestinal neoplasm) and to initiate appropriate therapy.
odynophagia
Pain on swallowing food and fluids (odynophagia) is possible in Mallory-Weiss tear due to tear or laceration of the esophagus.
pain
Degree, location (retrosternal, epigastric, or back pain), and character of the pain should be obtained from the patient. Hematemesis in Mallory-Weiss tear is sometimes accompanied by pain.
The main differential diagnosis in this group of patients is with Boerhaave syndrome (spontaneous rupture of the esophagus), which may have a similar presentation.
melena
Usually associated with upper gastrointestinal bleeding proximal to the ligament of Treitz. Confounding factors for melena include bismuth-containing products (e.g., Pepto-Bismol) and iron supplements.
hematochezia
Hematochezia is rare.
Hematochezia in Mallory-Weiss tear can be seen in an actively bleeding lesion in which the rapidity of the transit precludes any digestion of blood. Therefore, an unstable patient with hematochezia and other factors suggesting upper gastrointestinal bleeding requires urgent diagnosis and treatment.
shock
In most patients, hypovolemic shock is secondary to rapid blood loss. Shock in Mallory-Weiss tear is rare.[1]
Shock may suggest more serious underlying pathology such as esophageal varices, Dieulafoy lesion, actively bleeding peptic ulcer disease, or aortoenteric fistula.
signs of anemia
Rare in acute Mallory-Weiss tear.
Low Hb at presentation may indicate coexisting comorbidities. Signs of anemia include pallor, tachycardia, dyspnea, and fatigue.
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