Mallory-Weiss tear: Difference between revisions

(Mallory weiss tear)
 
 
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==Background==
==Background==
[[File:Gray1032.png|thumb|Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.]]
[[File:Layers of the GI Tract english.svg|thumb|Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.]]
[[File:Illu esophagus.jpg|thumb|Esophagus anatomy and nomenclature based on two systems.]]
*Longitudinal lacerations through mucosa and submucosa
*Longitudinal lacerations through mucosa and submucosa
*75% in proximal stomach, rest in distal esophagus  
*75% in proximal stomach, rest in distal esophagus  
*Due to sudden increase in intrabdominal pressure  
*Due to sudden increase in intrabdominal pressure  
**typically in the setting of forceful vomiting or retching  
**Typically in the setting of forceful vomiting or retching


==Clinical Presentation==
==Clinical Features==
===Risk Factors===
===Risk Factors===
*Hiatal hernia
*Hiatal hernia
*Alcoholism
*[[Alcoholism]]
*Anything that increases intrabdominal pressure: blunt abdominal trauma, CPR, etc.
*Anything that increases intrabdominal pressure: blunt [[abdominal trauma]], CPR, etc.
 
===History===
===History===
*Classic presentation: Hematemesis following vomiting or retching
*Classic presentation: [[Hematemesis]] following vomiting or retching
**As few as 30% of patients present this way
**As few as 30% of patients present this way
*Coffee ground emesis
*Coffee ground emesis
*Melena
*[[Melena]]
*Hematochezia
*Hematochezia


==Differential Diagnosis==
==Differential Diagnosis==
===Upper GI Bleed Differential===
{{UGIB DDX}}
*[[Peptic ulcer disease]]
*[[Gastritis]]/[[esophagitis]]
*Gastric/esophageal varices
*[[Mallory-Weiss tear]]
*Malignancy
*[[Aortoenteric fisulta]]
*[[Boerhaave]]
*Dieulafoy's lesion
*Angiodysplasia
*Hemobilia
*Hemorrhagic gastritis, EtOH
*Celiac
*Dengue
*Other intrabdominal bleeds
**Hemorrhagic pancreatitis
**Splenic rupture
**Subcapsular cavernous hemangiomas
**Peliosis hepatis
 
===Mimics of GI Bleeding===
*[[Hemoptysis]]
*[[Vaginal Bleeding (Main)|Vaginal]]/[[Hematuria|Urethra]] bleeding
*ENT bleeding
*Dietary (Iron, bismuth, beets)


==Diagnosis==
==Evaluation==
[[File:Mallory Weiss Tear.png|thumb|Mallory–Weiss tear affecting the esophageal side of the gastroesophageal junction.]]
*Approach as any GI bleed
*Approach as any GI bleed
**POC Hgb
**CBC
**CBC
**BMP
**Type and screen
**Type and screen
**Chemistry
**Guiac
**Guiac
**CXR
**[[CXR]]
*Definitive diagnosis by endoscopy
*Definitive diagnosis by endoscopy


==Management==
==Management==
*Most Mallory-Weiss tears are minor and resolve on their own.  However, up to 3% of UGIB deaths are a result of Mallory-Weiss tears.
*Most Mallory-Weiss tears are minor and resolve on their own, but up to 3% of upper gastrointestinal bleeding deaths are a result of Mallory-Weiss tears
*Treat as undifferentiated Upper GI bleed. 
*Endoscopy only for active and on-going bleeding<ref>Gyawali CP. The Washington Manual Gastroenterology Subspecialty Consult 2ed. 2008. Washington University School of Medicine.</ref>
*Treat as [[undifferentiated upper GI bleed]]
**Many of these patients are alcoholics and have cirrhosis; consider esophageal varices
**Many of these patients are alcoholics and have cirrhosis; consider esophageal varices
**History of vomiting/retching; consider [[boerhaave]]   
**History of vomiting/retching; consider [[boerhaave]]   
*Place 2 large bore IVs and monitor airway status
===Proton Pump Inhibitor===
*[[Pantoprazole]]/esomeprazole 80mg x 1; then 8mg/hr
*Reduces the rate of rebelling and need for surgery if there is an ulcer, but does not reduce morbidity or mortality<ref>Leontiadis GI et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2004(3):CD002094.</ref>
*There is a mortality benefit in Asian patients<ref>Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; [http://www.thennt.com/nnt/proton-pump-inhibitors-for-acute-peptic-ulcer- bleeding/] </ref>
===[[Antibiotics]]===
*[[Ceftriaxone]] 1gm daily x 7 days
**Indicated for pts w/ cirrhosis or history of ETOH abuse (regardless of whether bleeding is variceal or not)
===[[Erythromycin]]===
*Achieves endoscopy conditions equal to lavage<ref>Pateron D, et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Ann Emerg Med. 2011; 57(6):582-589.</ref>
*3mg/kg IV over 20-30min, 30-90min prior to endoscopy
=== [[IVF]]===
*Crystalloid can be used for initial resuscitation but should be limited due to the dilutional anemia and dilatational coagulopathy that can result
===PRBC [[transfusions]]===
*'''Indications for PRBC [[transfusions]]:'''
*Hemoglobin <7 g/dl
**Continued active bleeding
**Failure to improve perfusion and vital signs after infusion of 2L NS
**Varicele bleeding<ref>Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.</ref>
*In hemodynamically stable patients, the [[EBQ:Transfusion strategies for acute upper gastrointestinal bleeding | goal transfusion threshold should be 7 g/dl]]
*NICE guidelines recommend avoidance of over-transfusion<ref>Dworzynski K et al. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012;344:e3412.</ref>
===Other Blood Products===
*Cryopprecipitate to raise fibrinogen (goal >120mg/dL)
*Platelets (goal >50-100k/μL
*FFP can be used to correct anti coagulated patients
===Endoscopy===
*Endoscopy should be performed at the discretion of the gastroenterologist.  Early endoscopy does not necessarily improve clinical outcomes<ref>Sarin N et al. Time to endoscopy and out- comes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-493. </ref>
===[[Balloon tamponade]] with Sengstaken-Blakemore Tube===
*For life-threatening hemorrhage if endoscopy is not available)
*Tube consists of gastric and esophageal balloons
**First inflate gastric balloon; if bleeding continues inflate esophageal balloon
***Esophageal pressure must not exceed 40-50 mmHg
*Adverse reactions are frequent
**Mucosal ulceration
**Esophageal/gastric rupture
**Tracheal compression (consider intubation prior to balloon insertion)


===Treatments Not Supported by the Literature===
===Treatments Not Supported by the Literature===
*No evidence to support octreotide use
*No evidence to support octreotide use


==Disposition==
==Disposition==
*Anticipate admission


==See Also==
==See Also==
*[[Gastrointestinal bleeding]]
*[[Upper gastrointestinal bleeding]]


==External Links==
==External Links==
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==References==
==References==
<references/>
<references/>
[[Category:GI]]

Latest revision as of 22:32, 7 February 2024

Background

Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.
Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.
Esophagus anatomy and nomenclature based on two systems.
  • Longitudinal lacerations through mucosa and submucosa
  • 75% in proximal stomach, rest in distal esophagus
  • Due to sudden increase in intrabdominal pressure
    • Typically in the setting of forceful vomiting or retching

Clinical Features

Risk Factors

History

  • Classic presentation: Hematemesis following vomiting or retching
    • As few as 30% of patients present this way
  • Coffee ground emesis
  • Melena
  • Hematochezia

Differential Diagnosis

Upper gastrointestinal bleeding

Mimics of GI Bleeding

Evaluation

Mallory–Weiss tear affecting the esophageal side of the gastroesophageal junction.
  • Approach as any GI bleed
    • CBC
    • BMP
    • Type and screen
    • Guiac
    • CXR
  • Definitive diagnosis by endoscopy

Management

  • Most Mallory-Weiss tears are minor and resolve on their own, but up to 3% of upper gastrointestinal bleeding deaths are a result of Mallory-Weiss tears
  • Endoscopy only for active and on-going bleeding[1]
  • Treat as undifferentiated upper GI bleed
    • Many of these patients are alcoholics and have cirrhosis; consider esophageal varices
    • History of vomiting/retching; consider boerhaave

Treatments Not Supported by the Literature

  • No evidence to support octreotide use

Disposition

  • Anticipate admission

See Also

External Links

References

  1. ↑ Gyawali CP. The Washington Manual Gastroenterology Subspecialty Consult 2ed. 2008. Washington University School of Medicine.
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