Basics
Description
- 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 " � of stomach into esophagus during retching has been observed endoscopically.
- Responsible for � � �5% of all cases of upper GI bleeding
Etiology
- Associated with:
- Forceful coughing, laughing, or retching
- Lifting
- Straining
- Blunt abdominal trauma
- Seizures
- Childbirth
- Cardiopulmonary resuscitation
- Risk factors:
- Alcoholics:
- Especially after recent binge
- Patients with hiatal hernia
- Hyperemesis gravidarum
- Greater bleeding associated with:
- Portal hypertension
- Esophageal varices
- Coagulopathy
Diagnosis
Signs and Symptoms
History
- 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
Physical Exam
- Hematemesis
- Melena
- Postural hypotension
- Shock
Essential Workup
- CBC
- Rectal exam for occult blood
Diagnosis Tests & Interpretation
Lab
- 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
Imaging
- 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
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
Initial Stabilization/Therapy
- ABCs:
- 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
- Large-bore Ewald tube placement with evidence of large amount of bleeding:
- Safe
- Will not aggravate Mallory " �Weiss tear
- Lavage 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.
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:
- Electrocoagulation
- Injection therapy (epinephrine)
- Band ligation
- Hemoclips
- Application of blood-clotting agents
- Esophageal balloon tamponade
- Arterial embolization
- Intravenous vasopressin in massive bleeding and unavailable endoscopy
- In persistent/unresponsive hemorrhage, angiographic infusion of vasopressin
- Surgery " �last 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).
Medication
- Dopamine: 2 " �20 � �/kg/min IV piggyback (IVPB)
- Ondansetron 4 mg IV
- Pantoprazole 20 " �40 mg IV
- Vasopressin: 0.1 " �0.5 IU/min IVPB titrating up to 0.9 IU/min as necessary
Follow-Up
Disposition
Admission Criteria
- ICU admission for:
- Continued or massive hemorrhage
- Hemodynamic instability
- Extreme age
- Poor underlying medical condition
- Complications
- General floor admission for
- Stable patients with minimal bleed on presentation that has since cleared
- Patients with risk factors for rebleeding (portal HTN, coagulopathy)
Discharge Criteria
- History of minimal bleed that has stopped
- Hemodynamically stable
- Normal/stable hematocrit
- Negative or trace heme-positive stool
- Negative or trace gastric aspirate
Issues for Referral
Consult GI in ED if significant upper GI bleeding or if you suspect that requires urgent endoscopy. � �
Followup Recommendations
GI follow-up for outpatient endoscopy if clinically stable for discharge. � �
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 � �N, Inamori � �M, Sekino � �Y, et al. Risk factors for mortality in patients with Mallory-Weiss syndrome. Hepatogastroenterology. 2011;58:417 " �420.
- Kim � �JW, Kim � �HS, Byun � �JW, et al. Predictive factors of recurrent bleeding in Mallory-Weiss syndrome. Korean J Gastroenterol. 2005;46(6):447 " �454.
- Takhar � �SS. Upper gastrointestinal bleeding. In:Wolfson � �AB, Hendey � �GW,Ling � �LJ, et al., eds. Clinical Practice of Emergency Medicine. 5thed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:548 " �550.
- Wu � �JC, Chan � �FK. Esophageal bleeding disorders. Curr Opin Gastroenterol. 2004;20:386 " �390.
See Also (Topic, Algorithm, Electronic Media Element)
Gastrointestinal Bleeding � �
Codes
ICD9
530.7 Gastroesophageal laceration-hemorrhage syndrome � �
ICD10
K22.6 Gastro-esophageal laceration-hemorrhage syndrome � �
SNOMED
- 35265002 Mallory-Weiss syndrome (disorder)