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Mallory-Weiss syndrome
Mallory-Weiss syndrome is identified by acute upper gastrointestinal hemorrhage stemming from mucosal lacerations at or around the gastroesophageal junction. These lacerations, commonly a consequence of forceful retching in the context of gastric mucosal damage—often alcohol-related—present clinically as epigastric pain and hematemesis. In cases of significant bleeding, immediate hemodynamic stabilization via IV fluids or blood transfusion is critical. Endoscopic evaluation (EGD) serves as both a diagnostic and therapeutic tool, allowing for potential hemostasis. When EGD fails, angiography, and rarely surgery, may be alternatives. All patients should receive pharmacotherapy, including antiemetics and acid suppressants, although further intervention is typically unnecessary in the absence of ongoing bleeding.
Last updated: February 20, 2024
- Sex: ♂ > ♀ (3:1)
- Mallory-Weiss lesions account for approx. 5% of cases of gastrointestinal bleeding
- Mechanism:
- Caused by a sharp increase in esophageal intraluminal pressure.
- Leads to tears in the esophageal mucosa and submucosal arteries and veins.
- Precipitating Factors:
- Severe Vomiting: Excessive force during vomiting exerts high pressure on the esophagus.
- Blunt Abdominal Trauma: Can directly increase intra-abdominal and intraluminal esophageal pressure.
- Strained Defecation: Excessive straining can similarly elevate esophageal pressure.
- Predisposing Conditions:
- Alcohol Use Disorder: Associated with increased risk of severe vomiting and mucosal vulnerability.
- Bulimia Nervosa: Recurrent vomiting episodes can precipitate mucosal tears.
- Hiatal Hernia: Creates a higher pressure gradient at the gastroesophageal junction.
- Gastroesophageal Reflux Disease (GERD): Chronic acid exposure may weaken esophageal mucosa, increasing susceptibility to tears.
- May be asymptomatic
- Epigastric or back pain
- Hematemesis → May range from small streaks of blood to massive hemorrhage; typically follows a period of severe, bloodless vomiting
- Possible shock with massive hemorrhage → More severe bleeding is possible with concomitant drug use (e.g., anticoagulant therapy, nonsteroidal anti-inflammatory drugs) or certain comorbidities (e.g., portal hypertension, coagulopathy).
- Diagnosis is established by endoscopy, which shows a longitudinal tear (usually single) limited to the mucosa and submucosa at the gastroesophageal junction.
- Esophagogastroduodenoscopy is the gold standard test and can rule out other differential diagnoses of upper GI bleeding.
- Initial Management of Overt GI Bleeding:
- Hemodynamic Support: Immediate stabilization of the patient's vital signs.
- Emergency Blood Transfusion and Coagulopathy Correction: As required based on patient condition.
- Empiric Medical Therapy for GI Bleeding: General treatment for gastrointestinal bleeding.
- Pharmacological Therapy:
- Control Precipitating Factors and Predisposing Conditions: Addressing issues like nausea and vomiting.
- Acid Suppression:
- IV PPI Therapy: E.g., esomeprazole for acute management.
- Oral PPI Therapy: E.g., omeprazole or pantoprazole for ongoing management.
- Anticoagulant Reversal: Considered in cases of life-threatening bleeding.
- Antiemetic Therapy: E.g., ondansetron, promethazine for nausea, retching, or vomiting.
- Interventional Therapy:
- Evaluate the necessity based on the presence of active bleeding.
- Noninterventional management is often sufficient in the absence of active bleeding.
- Treating Underlying Conditions:
- Address conditions like alcohol use disorder, bulimia nervosa, etc., to prevent recurrence.
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