Mallory-Weiss syndrome: Clinical sciences

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Introduction0:00–0:32

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.

ABCDE assessment0:32–1:28

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.

Unstable patients - History and Physical1:28–2:23

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.

Diagnosis2:23–3:28

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.

Management3:28–4:01

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.Okay, now that unstable patients are taken care of, let's go back to the ABCDE assessment and talk about the stable ones.

Stable patient - History and Physical4:01–4:54

Your first step in assessing a stable patient is to obtain a focused history and physical exam, as well as labs including CBC and CMP.
As before, you can expect patients to report symptoms like hematemesis and possibly epigastric or back pain. They might also report a history of non-bloody emesis or retching.
Make sure to look for risk factors, such as alcohol use disorder. A physical exam is often unremarkable, so you might not find any evidence of active hematemesis.
On the other hand, labs might reveal anemia and electrolyte abnormalities. If you see these findings, suspect Mallory-Weiss syndrome.
Now, for anyone with suspected Mallory-Weiss syndrome, your next step is to assess for ongoing active bleeding. This is done by inserting in a nasogastric tube and monitoring its output.

Active Bleeding Assessment4:54–5:26

If the patient continues to have bloody output, they might have an active bleed. Additionally, serial CBCs can be obtained to trend the hemoglobin levels.
Downtrending hemoglobin supports an active bleed.Alright, let’s discuss the treatment for patients with active bleeding.

Active Bleeding5:26–6:21

First, start the patient on IV PPIs and antiemetics as needed. Then, obtain an urgent upper endoscopy within the first 24 hours of presentation.
Typically, you will see a single, longitudinal mucosal tear at or near the esophagogastric junction with some bleeding from the tear.
As before, you might also see additional tears, a visible bleeding vessel, adherent clots, as well as esophageal varices or hiatal hernia.
This confirms the diagnosis of Mallory-Weiss syndrome. Remember, endoscopy can be both diagnostic and therapeutic, so usually, measures to stop the bleeding are done in the same setting.
Once the bleeding is controlled and the patient’s hemoglobin is stable, they can be switched to oral PPIs and discharged home.
Now, if you didn’t see a Mallory-Weiss tear on endoscopy, then consider an alternative diagnosis of acute upper GI bleeding.

Alternative Diagnoses6:21–6:45

In many cases, you might see esophageal varices, which are a common finding as both Mallory-Weiss syndrome and esophageal varices are associated with alcohol use disorder.
Other important differentials include gastric ulcer or even cancer.Okay, now that the patients who are actively bleeding have been taken care of, let's go back and talk about patients without active bleeding.

No Active Bleeding6:45–7:11

In the majority of cases, you can prescribe oral PPIs and antiemetics if needed, and refer for an outpatient upper endoscopy within 72 hours of presentation.
As before, if you see a Mallory-Weiss tear on endoscopy, you have your diagnosis. Alright, as a quick recap… Mallory-Weiss syndrome is a superficial longitudinal mucosal tear at or near the gastroesophageal junction, often presenting as acute upper gastrointestinal bleeding.

Review7:11–7:57

If the patient is unstable, you should first stabilize the patient, start them on IV PPIs, and proceed with an emergent upper endoscopy to confirm the diagnosis and control the bleeding.
For stable patients, first assess for any active bleeding. Patients with active bleeding are managed with IV PPIs and urgent upper endoscopy in the first 24 hours of presentation.
If there’s no active bleeding on presentation, the patient can be treated on an outpatient basis with oral PPIs and an endoscopy within 72 hours.