Mallory-Weiss Syndrome

Introduction:

The esophagus, also known as the food pipe, is a part of the digestive tract connecting the throat and the stomach. In Mallory-Weiss syndrome, the inner lining of the esophagus splits open and starts bleeding. These splits are called Mallory-Weiss tears that may occur at or near the junction of the esophagus and stomach. It was in 1929 that Kenneth Mallory and Soma Weiss described this syndrome. The diagnosis of Mallory-Weiss syndrome is often confirmed through endoscopy. There is only a tear or split of the inner mucosa near the gastroesophageal junction. The average tear is two to four centimeters in length, and most patients often have only one split. The tear is usually present just beneath the gastroesophageal junction on the lesser curvature. Mallory-Weiss syndrome is considered one of the reasons for gastrointestinal bleeding.

What Are the Signs and Symptoms of Mallory-Weiss Syndrome?

• Pain in the abdomen.

• A history of severe vomiting.

• Presence of blood in vomiting (hematemesis).

• A strong involuntary effort to vomit (retching).

• Clotted blood has the appearance of “coffee grounds.”

• Stools as dark as tar (melanic).

• Painless, severe gastrointestinal bleeding due to tears in the mucous membrane. In some cases, such bleeding ceases spontaneously. In rare cases, the bleeding may become life-threatening.

What Is the Cause of Mallory-Weiss Syndrome?

Mallory-Weiss syndrome is believed to be caused by increased pressure in the abdomen. Researchers believe that the pressure in the abdomen forces the contents of the stomach into the esophagus resulting in tears. The possible causes of this increased abdominal pressure include:

• Severe retching or vomiting.

• Straining or heavy lifting.

• Coughing for prolonged periods.

• Trauma to the chest or abdomen.

• Cardiopulmonary resuscitation (CPR).

What Are the Risk Factors for Mallory-Weiss Syndrome?

Some conditions may increase the risk of developing Mallory-Weiss syndrome:

• Excessive Alcohol Use - It is considered as one of the most important predisposing factors as about 50 to 70 % of the patients with Mallory-Weiss syndrome have a history of alcohol abuse.

• Bulimia (an eating disorder that involves bingeing and vomiting).

• Esophageal varices (the veins of the esophagus get enlarged).

• Cyclic vomiting syndrome (recurrent attacks of vomiting, nausea, and exhaustion).

• Gastroesophageal reflux disease (stomach acid backs up in the esophagus and mouth).

• Hyperemesis gravidarum (severe vomiting during pregnancy).

• Portal hypertension (high blood pressure in the veins carrying blood from the digestive organs to the liver).

What Are the Complications of Mallory-Weiss Syndrome?

If Mallory-Weiss syndrome is left untreated, blood loss can cause fatigue, anemia, and shortness of breath. If the syndrome is severe and there is internal bleeding, the patient may experience symptoms of shock like:

• Agitation or anxiety.

• Nausea.

• Cold, pale, and clammy skin.

• Dry mouth or thirst.

• Shallow and rapid breathing.

• Rapid heartbeat or palpitations.

• Weakness.

How to Diagnose Mallory-Weiss Syndrome?

The diagnosis of Mallory-Weiss syndrome involves asking about medical history to asses the conditions causing the vomiting, straining, retching or coughing. A physical examination is also done to check for vital signs, and the patient will be assessed for severe bleeding or shock that may require emergency treatment. The doctor may also recommend blood tests such as complete blood count (CBC) or kidney function tests. The diagnostic test often used to diagnose Mallory-Weiss syndrome and rule out other disorders of the esophagus is upper endoscopy. During this test, the doctor inserts a thin, long flexible tube into the throat. Using a camera attached at the end of the tube, the doctor looks for the tears in the esophagus and upper stomach.

What Are the Treatment Options for Mallory-Weiss Syndrome?

The initial treatment involves stabilizing the general condition of the patient, and a conservative approach is adopted as the Mallory-Weiss syndrome is mostly self-limited and recurrence rates are very low.

• Initial Management - In patients with active bleeding, immediate resuscitation should be started at the time of admission. Hemodynamic stability is assessed by checking the airway, breathing, and circulation (ABC protocol). Good central or peripheral intravenous (IV) access is established, along with fluid replacement could prove to be life-saving in patients with severe bleeding. Packed RBCs (red blood cells) infusion is recommended in case the hemoglobin level is less than 8 gm/dl or the patient experiences signs of shock or severe bleeding. Nasogastric compression using a nasogastric tube is done in patients with suspected esophageal varices before gastric lavage. Electrolyte imbalance should be corrected accordingly. Before proceeding with endoscopy, coagulation factors need to optimize. Most patients are managed conservatively and are hospitalized until symptoms are resolved and hemostasis is achieved.

• Medications - H2 blockers and proton pump inhibitors are given to decrease gastric acidity as the acidity may hinder the recovery process of the gastric and esophageal mucosa. Intravenous proton pump inhibitors are given to patients who are suggested to go for endoscopy. Promethazine and Ondansetron are anti-emetics that are given to control nausea and vomiting.

• Endoscopic Treatment - In all cases of gastrointestinal bleeding, esophagogastroscopy is the choice of diagnostic test. In case the bleeding has already stopped at the time of endoscopy, no further intervention is required. But in cases of ongoing active or recurrent bleeding, there are different ways of endoscopic treatment. Epinephrine local injection is given that stops the bleeding through vasoconstriction. Other options are multipolar electrocoagulation (MPEC), injection of a sclerosant agent, endoscopic band ligation, or argon plasma coagulation (APC).

• Angiotherapy - Angiotherapy with either transcatheter embolization with gel or foam or injection of a vasoconstricting agent like vasopressin is considered to obliterate the left gastric or superior mesenteric artery in cases of endoscopy is not available or has failed.

• Surgical Treatment - Surgery is rarely needed and is recommended after a failed endoscopic treatment or angiography to stop bleeding. Laparoscopic over-sewing of the split under endoscopic guidance can be performed with excellent results.

Conclusion:

Mallory-Weiss syndrome can be described as the split, tear, or lacerations in the mucous membrane of the esophagus and the upper section of the stomach. Such a split can result in severe bleeding from the digestive tract. This syndrome is usually characterized by severe abdominal pain and a history of vomiting. The cause of the syndrome is often a protracted period of vomiting. The most often used diagnostic test for this syndrome is endoscopy. Mallory-Weiss syndrome is usually a self-limiting syndrome, and recurrence is uncommon.