Updated: 12/20/2019

Mallory-Weiss Tear

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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
 

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(M2.GI.16.44) A 43-year-old male is brought to the emergency department after his son found him vomiting bright red blood. He is visibly intoxicated, and hospital records indicate a long history of alcohol substance abuse treated with antabuse (disulfiram). Vital signs include T 98.4, HR 89, BP 154/92, and RR 20. EGD is notable for mild esophagitis, and a longitudinal esophageal tear at the gastroesophageal junction, with no active bleeding. What is the next best course of action? Tested Concept

QID: 102985
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Cyanoacrylate injection and ligation with banding, IV fluid hydration, and NPO

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Conservative management with IV fluid hydration and observation

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Barium swallow to characterize the depth of mucosal involvement

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Esophageal manometry and impedance studies

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5

Calcium channel blockage and Botox injection of the lower esophageal sphincter

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