Review Question - QID 102985

This man presents with bloody emesis after an episode of retching, and EGD demonstrates a longitudinal mucosal tear consistent with a Mallory-Weiss tear. Since there is no active bleeding, conservative management with IV hydration and observation is appropriate.

This man presents with a history of hematemesis. His history of alcohol abuse should warrant concern for possible variceal bleeding secondary to portal hypertension, however his esophagogastroduodenoscopy demonstrates no varices and instead shows a longitudinal mucosal tear consistent with a Mallory Weiss tear. Mallory-Weiss syndrome accounts for approximately 5% of patients presenting with hematemesis and often occurs in the setting of a hiatal hernia. Once diagnosed, management is supportive in nature. An EGD is a sensitive and specific study to fully characterize the lesion.

Wilkins et al. discuss the etiology of upper GI bleeds and note the high prevalence of non-variceal bleeds being associated with the use of NSAIDS. Peptic ulcer bleeding causes more than 60% of cases of upper gastrointestinal bleeding, whereas esophageal varices cause approximately 6 %. Other etiologies include arteriovenous malformations, Mallory-Weiss tear, gastritis and duodenitis, and malignancy.

Cremers et al. detail the importance of approaching the cirrhotic patient with an upper GI bleed. Delineating whether the bleed is a result of portal hypertension/varices as opposed to bleeding from conditions of the general population (peptic ulcer, erosive gastritis, reflux esophagitis, Mallory-Weiss syndrome, tumors, etc.) is key to determining the next step in management. Bleeding from gastric varices is treated by injection with cyanoacrylate. Treatment with vasoactive drugs as well as antibiotic treatment is started before or at the same time as endoscopy.

Illustration A is an EGD demonstrating a mucosal tear at the GE junction known as a Mallory-Weiss tear. Illustration B is an EGD demonstrating esophageal varices with prominent cherry-red spots.

Incorrect Answers:
Incorrect Answer 1: Cyanoacrylate injection and ligation with banding is the preferred therapy for esophageal varices. This patient is at risk of portal hypertension and cirrhosis due to his documented history of alcohol abuse, however, EGD did not demonstrate any varices.
Incorrect Answer 3: An upper GI series is an effective, non-invasive diagnostic study to evaluate esophageal pathology. However, the definitive diagnosis with EGD obviates the need for further characterization.
Incorrect Answer 4: Esophageal manometry and impedance studies are central to the diagnosis of esophageal motility pathology such as diffuse esophageal spasms and achalasia. They play no role in this clinical presentation.
Incorrect Answer 5: Calcium channel blockers and Botox has been used by GI interventionalist to help manage symptoms of achalasia. Definitive therapy for achalasia is with esophageal dilation. This treatment has no role to play in a patient with Mallory-Weiss Syndrome.