Mallory-Weiss Syndrome

Essentials of Diagnosis

• Hematemesis; usually self-limited

• Prior history of vomiting, retching in 50%

• Endoscopy establishes diagnosis

General Considerations

• Characterized by a nonpenetrating mucosal tear at the gastroesophageal junction

• Events that suddenly raise transabdominal pressure, such as lifting, retching, or vomiting, may be contributory

• Alcoholism is a strong predisposing factor

• Accounts for ~5% of upper gastrointestinal bleeding

Symptoms and Signs

• History of vomiting, retching, straining in 50%

• Hematemesis with or without melena

Differential Diagnosis

OTHER CAUSES OF HEMATEMESIS

• Hemoptysis

• Erosive esophagitis

• Peptic ulcer disease

• Esophageal or gastric varices

• Erosive gastritis, eg, nonsteroidal anti-inflammatory drugs, alcohol, stress

• Portal hypertensive gastropathy

• Vascular ectasias (angiodysplasias)

• Gastric cancer

RARE CAUSES

• Aortoenteric fistula

• Dieulafoy lesion (aberrant gastric submucosal artery)

• Hemobilia (blood in biliary tree), eg, iatrogenic, malignancy

• Pancreatic cancer

• Hemosuccus pancreaticus (pancreatic pseudoaneurysm)

Laboratory Tests

• Complete blood count

• Platelet count

• Prothrombin time

• Partial thromboplastin time

• Serum creatinine

• Liver enzymes and serologies

• Type and cross-matching for 2–4 units or more of packed red blood cells

• Hematocrit is not a reliable indicator of the severity of acute bleeding

Diagnostic Procedures

• Upper endoscopy

  • Diagnostic

  • Identifies a 0.5–4.0 cm linear mucosal tear usually located either at the gastroesophageal junction or, more commonly, just below the junction in the gastric mucosa

Surgery

• Angiographic arterial embolization or operative intervention is required in patients in whom endoscopic therapy fails

Therapeutic Procedures

• Patients are initially treated as needed with fluid resuscitation and blood transfusions

• Most patients stop bleeding spontaneously and require no therapy

• Endoscopic hemostatic therapy is employed in patients who have continuing active bleeding

• Injection with epinephrine (1:10,000), cautery with a bipolar or heater probe coagulation device, or mechanical compression of the artery by application of an endoclip or band is effective in 90–95% of cases

Follow-Up

• None required

Complications

• Persistent bleeding

Prognosis

• Most Mallory-Weiss bleeds stop spontaneously with rapid healing of mucosal tears

• Persistent or recurrent bleeding most likely in patients with concomitant portal hypertension or coagulopathy

When to Admit

• All patients with significant hematemesis