Mallory-Weiss tear

Background

• 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 Presentation

Risk Factors

• Hiatal hernia
• Alcoholism
• Anything that increases intrabdominal pressure: blunt abdominal trauma, CPR, etc.

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 GI Bleed Differential

• 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/Urethra bleeding
• ENT bleeding
• Dietary (Iron, bismuth, beets)

Diagnosis

• Approach as any GI bleed
  • POC Hgb
  • CBC
  • Type and screen
  • Chemistry
  • Guiac
  • CXR
• Definitive diagnosis by endoscopy

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.
• Treat as undifferentiated Upper GI bleed.
  • Many of these patients are alcoholics and have cirrhosis; consider esophageal varices
  • 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
• There is a mortality benefit in Asian patients

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
• 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
• In hemodynamically stable patients, the goal transfusion threshold should be 7 g/dl
• NICE guidelines recommend avoidance of over-transfusion

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

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

• No evidence to support octreotide use