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Mallory–Weiss Syndrome, Emergency Medicine

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Mallory–Weiss Syndrome, Emergency Medicine

Basics

Description

Consult GI in ED if significant upper GI bleeding or if you suspect that requires urgent endoscopy. пїЅ пїЅ

GI follow-up for outpatient endoscopy if clinically stable for discharge. пїЅ пїЅ

530.7 Gastroesophageal laceration-hemorrhage syndrome пїЅ пїЅ

  • Partial-thickness intraluminal longitudinal mucosal tear of distal esophagus or proximal stomach
  • Sudden increase in intra-abdominal and/or transgastric pressure causes:Mild to moderate submucosal arterial and/or venous bleeding:May be related to underlying pathology "Mushrooming " пїЅ of stomach into esophagus during retching has been observed endoscopically.Responsible for пїЅ пїЅ пїЅ5% of all cases of upper GI bleeding
  • Mild to moderate submucosal arterial and/or venous bleeding:May be related to underlying pathology "Mushrooming " пїЅ of stomach into esophagus during retching has been observed endoscopically.
  • Responsible for пїЅ пїЅ пїЅ5% of all cases of upper GI bleeding
  • May be related to underlying pathology
  • "Mushrooming " пїЅ of stomach into esophagus during retching has been observed endoscopically.

Etiology

  • Associated with:Forceful coughing, laughing, or retchingLiftingStrainingBlunt abdominal traumaSeizuresChildbirthCardiopulmonary resuscitation
  • Risk factors:Alcoholics:Especially after recent bingePatients with hiatal herniaHyperemesis gravidarum
  • Greater bleeding associated with:Portal hypertensionEsophageal varicesCoagulopathy
  • Forceful coughing, laughing, or retching
  • Lifting
  • Straining
  • Blunt abdominal trauma
  • Seizures
  • Childbirth
  • Cardiopulmonary resuscitation
  • Alcoholics:Especially after recent binge
  • Patients with hiatal hernia
  • Hyperemesis gravidarum
  • Especially after recent binge
  • Portal hypertension
  • Esophageal varices
  • Coagulopathy

Diagnosis

Signs and Symptoms

  • Multiple bouts of nonbloody vomiting and/or retching followed by hematemesis:Most bleeding is small and resolves spontaneously.Massive life-threatening hemorrhage can occur.
  • Epigastric pain
  • Back pain
  • Dehydration:Dizzy, light-headed; syncope
  • Most bleeding is small and resolves spontaneously.
  • Massive life-threatening hemorrhage can occur.
  • Dizzy, light-headed; syncope
  • Hematemesis
  • Melena
  • Postural hypotension
  • Shock

Essential Workup

  • CBC
  • Rectal exam for occult blood

Diagnosis Tests & Interpretation

  • Prothrombin time (PT), partial thromboplastin time (PTT), INR
  • Electrolytes, BUN, creatinine, glucose, LFTs
  • Amylase/lipase if abdominal pain
  • Type and cross-match:At least 4 U of packed red blood cells (PRBCs) if bleeding is severe
  • ECG if elderly or with cardiac history
  • At least 4 U of packed red blood cells (PRBCs) if bleeding is severe
  • Upright chest radiograph for free air from esophageal or gastric perforation
  • Upper endoscopy (esophagogastroscopy):Procedure of choice to locate, identify, and treat source of bleeding
  • Procedure of choice to locate, identify, and treat source of bleeding

Differential Diagnosis

  • Nasopharyngeal bleeding
  • Hemoptysis
  • Esophageal rupture (Boerhaave syndrome)
  • Esophagitis
  • Gastritis
  • Gastroenteritis
  • Duodenitis
  • Ulcer disease
  • Varices
  • Carcinoma
  • Vascular-enteric fistula
  • Hemangioma

Treatment

Pre-Hospital

  • Airway control:100% oxygen or intubate if unresponsive or airway patency in jeopardy
  • If hemodynamically unstable or massive hemorrhage:Initiate 2 large-bore IV catheters.1 L bolus (peds: 20 mL/kg) lactated Ringer (LR) solution or 0.9% normal saline (NS)Trendelenburg position
  • 100% oxygen or intubate if unresponsive or airway patency in jeopardy
  • Initiate 2 large-bore IV catheters.
  • 1 L bolus (peds: 20 mL/kg) lactated Ringer (LR) solution or 0.9% normal saline (NS)
  • Trendelenburg position

Initial Stabilization/Therapy

  • ABCs:IV access with at least 1 large-bore catheter; more if unstableCentral catheter placement if unstable for more efficient delivery of fluids and monitoring of central venous pressureIV fluids of either 0.9% NS (or LR) at 250 mL/h if stable; wide open if hemodynamically unstableDopamine for persistent hypotension unresponsive to aggressive fluid resuscitation
  • Large-bore Ewald tube placement with evidence of large amount of bleeding:SafeWill not aggravate Mallory " пїЅWeiss tearLavage blood from stomach with water while patient is on side in Trendelenburg position.
  • Nasogastric (NG) tube placement to check for active bleeding
  • Transfuse O-negative red blood cells immediately if hypotensive and not responsive to 2 L of crystalloid.
  • Most bleeding stops spontaneously with conservative therapy.
  • IV access with at least 1 large-bore catheter; more if unstable
  • Central catheter placement if unstable for more efficient delivery of fluids and monitoring of central venous pressure
  • IV fluids of either 0.9% NS (or LR) at 250 mL/h if stable; wide open if hemodynamically unstable
  • Dopamine for persistent hypotension unresponsive to aggressive fluid resuscitation
  • Safe
  • Will not aggravate Mallory " пїЅWeiss tear
  • Lavage blood from stomach with water while patient is on side in Trendelenburg position.

Ed Treatment/Procedures

  • NPO
  • Transfuse PRBCs if unstable or lowering hematocrit with continued hemorrhage.
  • Place Foley catheter to monitor urine output.
  • Monitor fluid status closely.
  • With continuing hemorrhage, arrange for immediate endoscopy:Control bleeding endoscopically via:ElectrocoagulationInjection therapy (epinephrine)Band ligationHemoclipsApplication of blood-clotting agentsEsophageal balloon tamponadeArterial embolization
  • Intravenous vasopressin in massive bleeding and unavailable endoscopy
  • In persistent/unresponsive hemorrhage, angiographic infusion of vasopressin
  • Surgery " пїЅlast but definitive treatment modality using techniques to oversew bleeding site or perform gastrectomy
  • Failure of above may require gastric arterial embolization in patients of poor surgical risk.
  • Antiemetics for nausea/vomiting
  • Proton pump inhibitors or H2 blockers for gastric acid suppression.
  • Avoid Sengstaken-Blakemore tubes (especially in presence of hiatal hernia).
  • Control bleeding endoscopically via:ElectrocoagulationInjection therapy (epinephrine)Band ligationHemoclipsApplication of blood-clotting agents
  • Esophageal balloon tamponade
  • Arterial embolization
  • Electrocoagulation
  • Injection therapy (epinephrine)
  • Band ligation
  • Hemoclips
  • Application of blood-clotting agents

Medication

  • Dopamine: 2 " пїЅ20 пїЅ пїЅ/kg/min IV piggyback (IVPB)
  • Ondansetron 4 mg IV
  • Pantoprazole 20 " пїЅ40 mg IV
  • Vasopressin: 0.1 " пїЅ0.5 IU/min IVPB titrating up to 0.9 IU/min as necessary

Follow-Up

Disposition

  • ICU admission for:Continued or massive hemorrhageHemodynamic instabilityExtreme agePoor underlying medical conditionComplications
  • General floor admission forStable patients with minimal bleed on presentation that has since clearedPatients with risk factors for rebleeding (portal HTN, coagulopathy)
  • Continued or massive hemorrhage
  • Hemodynamic instability
  • Extreme age
  • Poor underlying medical condition
  • Complications
  • Stable patients with minimal bleed on presentation that has since cleared
  • Patients with risk factors for rebleeding (portal HTN, coagulopathy)
  • History of minimal bleed that has stopped
  • Hemodynamically stable
  • Normal/stable hematocrit
  • Negative or trace heme-positive stool
  • Negative or trace gastric aspirate

Followup Recommendations

Pearls and Pitfalls

  • Place 2 large-bore IVs for patients with upper GI bleed.
  • For massive GI bleed, initiate blood transfusion early.
  • Contact GI early for emergent endoscopy with significant bleeding.
  • Active bleeding at the time of initial endoscopy and a low initial hematocrit is associated with a complicated clinical course.
  • Rebleeding usually occurs within 24 hr, and is most common in patients with coagulopathies.

Additional Reading

  • Fujisawa пїЅ пїЅN, Inamori пїЅ пїЅM, Sekino пїЅ пїЅY, et al. Risk factors for mortality in patients with Mallory-Weiss syndrome. Hepatogastroenterology. 2011;58:417 " пїЅ420.
  • Kim пїЅ пїЅJW, Kim пїЅ пїЅHS, Byun пїЅ пїЅJW, et al. Predictive factors of recurrent bleeding in Mallory-Weiss syndrome. Korean J Gastroenterol. 2005;46(6):447 " пїЅ454.
  • Takhar пїЅ пїЅSS. Upper gastrointestinal bleeding. In:Wolfson пїЅ пїЅAB, Hendey пїЅ пїЅGW,Ling пїЅ пїЅLJ, et al., eds. Clinical Practice of Emergency Medicine. 5thed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:548 " пїЅ550.
  • Wu пїЅ пїЅJC, Chan пїЅ пїЅFK. Esophageal bleeding disorders. Curr Opin Gastroenterol. 2004;20:386 " пїЅ390.

See Also (Topic, Algorithm, Electronic Media Element)

Codes

ICD9

ICD10

SNOMED

  • 35265002 Mallory-Weiss syndrome (disorder)