Mallory-Weiss syndrome: Clinical sciences

Mallory-Weiss syndrome, also known as a Mallory-Weiss tear, is a superficial longitudinal mucosal tear at or near the gastroesophageal junction, often presenting as acute upper gastrointestinal bleeding. These mucosal tears occur after repetitive and forceful retching and vomiting, most frequently from alcohol use disorder. The tear can cause severe bleeding if there are other comorbidities, such as portal hypertension or esophageal varices.

Alright, when assessing a patient with a chief concern suggestive of Mallory-Weiss syndrome, your first step is to perform an ABCDE assessment to determine if they are stable or unstable. If the patient is unstable, stabilize the airway, breathing, and circulation. First, check the airway for any compromise. You might need to intubate if the patient is at risk for aspiration.

Next, obtain IV access and initiate IV fluids for resuscitation. Consider transfusion of blood products for patients with significant blood loss. Additionally, insert a nasogastric tube and keep the patient NPO. Then, continuously monitor vital signs including pulse oximetry, blood pressure, and heart rate. Finally, be sure to admit these patients to the ICU for close monitoring, as they might deteriorate further.

Once you’ve initiated acute management, your next step is to obtain a focused history and physical exam, as well as labs including CBC and CMP. Patients often report a history of hematemesis, sometimes with epigastric or back pain, and non-bloody emesis and retching. They might have risk factors, such as alcohol use disorder or ingestion of acetylsalicylic acid.

On physical exam, you may find evidence of massive hematemesis, such as a large pool of bloody vomitus, in addition to hypotension and tachycardia. Finally, CBC might show decreased hemoglobin, while CMP might show electrolyte abnormalities suggestive of acute blood loss anemia and dehydration. If this is the clinical presentation, you should suspect an acute upper GI bleed from Mallory-Weiss syndrome.

Now let’s talk about the workup for an unstable patient. Since your patient is actively and acutely bleeding, once resuscitation is done and they are admitted to the ICU, your next step is to start the patient on IV proton pump inhibitors, or PPIs for short, and administer antiemetics as needed to control the vomiting. Then, perform an emergent upper GI endoscopy.

In this case, the endoscopy is both diagnostic and therapeutic, as it provides direct visualization of the tear and the bleeding, and allows for endoscopic intervention, which can stop the bleeding. On endoscopy, you’ll see a single, superficial longitudinal mucosal tear at or near the esophagogastric junction. Additionally, you might see the bleeding vessel, sometimes with an adherent clot, as well as other comorbidities like esophageal varices or hiatal hernia. If you see these findings, the diagnosis is Mallory-Weiss syndrome.

Alright, let’s move on to treatment. As you’re already doing endoscopy, start with endoscopic intervention to try and stop the bleeding. This can involve injection of sclerosing agents, cauterization, or clips or bands, which all work in different ways to tamponade the bleeding vessel. Also, be sure to check serial hemoglobin levels to assess for improvement. However, if the patient continues to bleed despite endoscopic measures, consult the interventional radiology team for angioembolization of the bleeding vessel.