Mallory Weiss Tear - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

Mallory Weiss tears are longitudinal superficial mucosal lacerations that cause acute upper gastrointestinal bleeding. It causes Mallory Weiss syndrome. Primarily these lacerations are present at the gastroesophageal junction and extend proximally to the lower and mid esophagus. Sometimes it extends distally to involve the proximal region of the stomach.

Albers first reported lower esophageal ulceration in 1833. Still, in 1929 Kenneth Mallory and Soma Weiss accurately described this condition as lower esophageal lacerations with vomiting and repetitive forceful retching after excessive alcohol consumption. Generally, the Mallory Weiss tears are self-limiting as they heal themselves, and the recurrence rate is the least. However, conservative treatment can be approached in most patients.

What Are the Causes of Mallory Weiss Tears?

• The most important predisposing factor in about 50% to 70% of patients is excessive alcohol consumption.

• Mallory Weiss syndrome is reported in cases of portal hypertension (increased portal venous system pressure) and esophageal varices (enlargement of esophageal pressure).

• Repeated acts of sudden elevation in Intra Abdominal pressure such as vomiting, retching, straining, coughing, blunt abdominal traumas, and cardiopulmonary resuscitation (CPR). These conditions act as precipitating factors for Mallory Weiss syndrome.

• It can also be a complication of procedures like upper gastrointestinal endoscopy or trans-esophageal echocardiography (TEE).

  Related Topics

  ---

  After an episode of vomiting blood, my blood report indicates an increased monocyte count. Why?

  Vomit Color Chart: Its interpretations and Indications

  Black or Tarry Stools - Causes, Diagnosis, Prevention and Treatment

• The relation between Hiatal hernia and Mallory Weiss tears is still in debate. Hiatal hernia is a protrusion of an organ (generally the upper region of the stomach) into the chest cavity through the esophageal opening of the diaphragm. It was observed that a good number of cases of Mallory Weiss syndrome had hiatal hernia.

What Are the Symptoms Caused by Mallory Weiss Tears?

• The mild cases of Mallory tear are usually asymptomatic, which means they present no symptoms.

• The basic symptom is hematemesis (vomiting with blood) in moderate or severe cases. The amount of blood varies from blood-streaked mucus to a large amount of bright red bleeding.

• In excess bleeding, there can be symptoms such as dizziness, melena (dark, sticky feces containing partly digested blood), or syncope. There can be epigastric pain in cases such as gastroesophageal reflux disease (GERD).

How to Evaluate Mallory Weiss Tears?

• Physical Examination: The first and most important step is a good physical examination and medical history. The doctor should look for signs of shock and bleeding, tachycardia (an increase in heartbeat), hypotension (decreased blood pressure), dehydration, reduced skin turgor (skin flexibility), and presence of melena in the stool.

• Blood Tests: Basic blood tests include a complete blood count coagulation profile (bleeding time, platelet count, partial prothrombin type, and prothrombin type).

• Endoscopy: Upper gastrointestinal tract endoscopy is the most useful procedure to diagnose Mallory Weiss tears. It helps to demonstrate active bleeding, clot formation, or a fibrin crust over the tear. In most cases, a single linear tear on the proximal part of the downward curvature of the stomach, just below the cardia, confirms the diagnosis of Mallory Weiss tears. The technique also helps to manage some simple active esophageal bleeding.

• Angiography: In some cases where there is inaccessibility or failure of endoscopy to reach the site of the tear, angiography is used to locate and stop the bleeding.

What is the treatment for Mallory Weiss tears?

• Mallory Weiss tears are self-limiting and self-curing with the least recurrence rate. Thus the initial step for management includes stabilizing the general symptoms of the patient and a conservative approach to the treatment.

• As soon as the patient is admitted, hemodynamic stability should be assessed by checking the airway, breathing, and circulation (ABC protocol). Administration of fluid by peripheral or central intravenous technique could be a life-saving step in cases of severe bleeding. If the hemorrhage level is reduced below 8 gm/dl, packed RBCs (red blood cells) infusion is advised.

• Pharmacological Treatment: Increased gastric acidity can hinder the recovery of esophageal or gastric mucosa, so proton pump inhibitors or H2 blockers are given. Intravenous proton pump inhibitors are given to patients expected for endoscopic examination. In cases of nausea and vomiting, anti-emetics such as promethazine and ondansetron are given.

• Endoscopic Approach: In cases of continued bleeding from the esophagus, endoscopy is very important to stop the bleeding. Different modalities of esophagogastroscopy are:

1. Epinephrine local injection (1:10,000 to 1:20,000 dilution) helps stop the bleeding due to vasoconstriction.

2. Multipolar Electrocoagulation (MPEC). A sclerosant agent injection, argon plasma coagulation (APC), or endoscopic band ligation.

• Angiography: When endoscopy is not the choice of treatment, then injection of a vasoconstricting agent such as vasopressin or a transcatheter embolization with gel foam to obliterate the left gastric or superior mesenteric artery is considered.

• Surgery: Surgical treatment is a rare treatment choice when endoscopic or radiotherapy fails to stop bleeding. Laparoscopy shows excellent results in such cases.

• Sengstaken- Blakemore Tube Compression: This is considered the last resort of treatment for bleeding Mallory Weiss tear. It is least preferred because the bleeding is mostly arterial, and the pressure of the balloon is not enough to overcome the pressure in the bleeding artery.

Which Diseases Are Similar to Mallory Weiss Tears?

• Peptic Ulcer: It is soreness on the lining of the stomach, intestine, or esophagus leading to gastrointestinal bleeding.

• Boerhaave Syndrome: Any perforation of the esophagus resulting from a sudden increase in intraesophageal pressure with negative intrathoracic pressure.

• Esophageal Varices: An enlargement of the esophagus veins due to obstructed blood flow to the portal vein.

• Arteriovenous malformations: An abnormal tangle of blood vessels that connect arteries and veins and then disrupt normal blood flow and oxygen circulation.

• Esophageal or Gastric Neoplasm: Malignancy or cancer affecting the esophagus or gastrointestinal tract.

Conclusion:

Mallory Weiss tears are lacerations on the gastroesophageal junction, extending proximally to the middle and lower esophagus. These tears are the reason for upper gastrointestinal bleeding. There is no symptom in cases of mild tears, but in moderate and severe cases, there is hematemesis, dizziness, and sticky stools. Generally, Mallory Weiss tears are self-limiting as they can heal themselves, and the recurrence rate is very low.