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Updated: Dec 11 2021

Mallory-Weiss Tear

Images weiss.jpg
  • Snapshot
    • A 53-year-old man with a history of gastroesophageal reflux and alcohol abuse is brought to the emergency room by his family due to acute chest and back pain. He endorses alcohol use throughout the day and has been feeling very nauseated with emesis throughout the night. On evaluation, his blood pressure is 105/72 mmHg and pulse is 92/min. He had 1 episode of emesis with bright red blood in the room.
  • Introduction
    • Clinical definition
      • longitudinal mucosal tear at the gastroesophageal junction or gastric cardia
  • Epidemiology
    • Up to 15% of all upper gastrointestinal bleeding
    • Demographics
      • middle age
      • higher incidence in men
    • Risk factors
      • alcoholism
      • hiatal hernia
      • eating disorder
      • food poisoning
    • Pathogenesis
      • rapid increase in intraabdominal pressure
        • most commonly from forceful and repeated emesis
        • straining
        • coughing
        • blunt abdominal trauma
  • Presentation
    • Symptoms
      • hematemesis ranging from streaks to bright red blood
      • melena or hematochezia
      • epigastric pain
      • back pain
      • dizziness
    • Physical exam
      • tachycardia or hypotension
      • guaiac positive stool
  • Studies
    • Diagnostic testing
      • studies
        • esophagogastroduodenoscopy
          • visualizes tear and is diagnostic
  • Differential
    • Reflux esophagitis
      • distinguishing factor
        • irregularly shaped ulcerations
    • Boerhaave syndrome
      • distinguishing factor
        • transmural esophageal tear
  • Treatment
    • Management approach
      • initiate resuscitative measures to stabilize
        • fluid resuscitation and blood replacement for hemodynamic support
      • prompt diagnostic and therapeutic endoscopy for definitive treatment
      • manage precipitating and exacerbating factors
        • proton pump inhibitors
          • sufficient as monotherapy for tears that are not actively bleeding
        • antiemetics
      • monitor for complications
        • electrocardiogram and cardiac enzymes for secondary myocardial ischemia
        • coagulation studies and complete blood count for coagulopathy and thrombocytopenia
    • First-line
      • endoscopic treatment
        • indicated for active bleeding only (90% are self-limited)
        • combined with epinephrine or sclerosant injection, thermal coagulation, banding, or hemoclips
    • Second-line
      • angiotherapy
        • indicated for failed endoscopic management
        • often with left gastric artery embolization
    • Third-line
      • surgery
        • indicated for failed endoscopic management and angiotherapy, rarely used
        • oversew mucosal tear
  • Complications
    • Rebleed
    • Myocardial ischemia or infarction
    • Hypovolemic shock
    • Death
1 of 0
1 of 3
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