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Mallory-Weiss Syndrome

Gastro Esophageal Laceration Syndrome

Mallory–Weiss syndrome refers to the development of mucosal tears at the gastroesophageal junction, commonly due to chronic vomiting, retching, and hiccuping. It can occur in many diseases in which vomiting is a symptom, and it is one of the most common causes of upper gastrointestinal hemorrhage. Bleeding may be small, or even profuse, and necessitate prompt treatment, which is directed at stabilizing the patient, but also at managing the underlying cause.


Presentation

Mallory-Weiss syndrome may be initially asymptomatic, especially in mild cases, when mucosal lacerations produce minimal bleeding and spontaneously heal without treatment. However, the majority of patients present with hematemesis and melena, accompanied by other symptoms, such as abdominal pain, severe vomiting and involuntary retching [9]. In the case of melena and hematemesis, immediate investigation of the underlying cause should be made, to prevent further blood loss and to establish the source of bleeding. This may be particularly useful in cases when blood loss from mucosal tears in Mallory-Weiss syndrome is profound and possibly life-threatening. In such circumstances patients may experience shock, hypotension and poor general condition, which necessitates immediate treatment [10].

Other conditions that present with hematemesis, such as peptic ulcer disease, esophageal perforation, chronic erosive gastritis and esophageal varices, should be excluded during the diagnostic workup.

Cough
  • A 62-year-old man with a chief complaint of coughing up blood was revealed to have Mallory-Weiss syndrome with arterial bleeding by gastrointestinal endoscopy at the esophagogastric junction, and two teardrop-shaped fissures were found longitudinally[ncbi.nlm.nih.gov]
  • Mallory-Weiss tears classically follow severe bouts of retching, coughing, or vomiting, all of which result in large spikes in gastric pressure.[pathwaymedicine.org]
  • Symptoms A person with this condition will vomit blood or pass black, sticky stools after periods of vomiting, retching or coughing. Immediate medical attention should be sought if these symptoms are present.[cedars-sinai.edu]
  • Chronic cough or acute causes of prolonged coughing bouts. For example Chronic obstructive pulmonary disease (COPD). Cancer of the lung. Bronchiectasis. Whooping cough. Bronchitis. Hiatus hernia.[patient.info]
Snoring
  • A Mallory-Weiss gastric mucosa laceration and upper gastrointestinal bleed was caused by intense snoring. This cause of gastrointestinal hemorrhage should be considered in the patient who snores.[ncbi.nlm.nih.gov]
  • The different predisposing factors include hiatal hernia , severe traumatic injury to the abdomen or chest, extreme snoring, straining and lifting, tenderness of the lining of the esophagus (esophagitis) or stomach (gastritis), cardiopulmonary resuscitation[syndromespedia.com]
  • Some of the conditions causing Mallory-Weiss tears are: Any sort of traumatic injury to the chest or abdomen Severe persistent episodes of hiccups Severe coughing Persistent snoring Activities like heavy lifting Gastritis Hiatal hernia Convulsions.[epainassist.com]
  • A cause of sudden unexpected death due to massive haematemesis without antecedent vomiting. ( 3570703 ) O'Reilly U....Connolly C.E. 1987 49 Snore-induced Mallory-Weiss syndrome. ( 3559121 ) Merrill J.R. 1987 50 The Mallory-Weiss syndrome.[malacards.org]
Pleural Effusion
  • effusion, Mediastinal widening, Subcutaneous emphysema, Nacleiro sign [a V-shaped radiolucency seen through the heart representing air in the left lower mediastinum that dissects under the left diaphragmatic pleura] In neonatal rupture, pneumomediastinum[prep4usmle.com]
Fever
  • The most common symptoms of chikungunya virus infection are fever and joint pain. Other symptoms may include headache, muscle pain, joint swelling, or rash.[gastrointestinalatlas.com]
  • […] is mucosal and patient present with upper gi bleed and in Boerhaave's esophagus is perforated through all layers, which basically leads to mediastinitis, which is potentially lethal, and manifests with very severe substernal pain initially and then fever[prep4usmle.com]
  • Although 7 per cent of patients may be asymptomatic, oesophageal perforation usually causes severe thoracic pain, followed by fever, dysphagia, mediastinal and subcutaneous emphysema, and ultimately dyspnoea and systemic sepsis.[ots1.narod.ru]
Pallor
  • Signs are pallor; tachyardia; in some patients shock. Prevalent in males, usually onset after 30 years of age - it takes some time and effort to drink that much. First described by Heinrich Irrenaeus Quincke (1842-1922) in 1879.[whonamedit.com]
Vomiting
  • The lacerations are most commonly gastric and are associated with other mucosal lesions which may in fact be the instigating cause of the retching and vomiting.[ncbi.nlm.nih.gov]
  • The characteristic history consists of repeated vomiting followed by sudden haematemesis. During the past 4 1/2 years, 23 patients, 17 males and 6 females with the diagnosis of Mallory-Weiss syndrome were treated in our institution.[ncbi.nlm.nih.gov]
  • Retching was the most common precipitating factor (5/6) followed by vomiting (2/6).[ncbi.nlm.nih.gov]
  • Forceful vomiting can tear the esophagus. Symptoms The first symptom of Mallory-Weiss syndrome is usually the appearance of bright-red blood in vomit. Vomiting blood is called hematemesis.[merckmanuals.com]
Hematemesis
  • We present here a case of sudden onset of wretching and vomiting after IV infusion of cis-platinum for recurrent carcinoma of the uterine cervix in which the patient had profuse hematemesis secondary to three posterior gastroesophageal tears requiring[ncbi.nlm.nih.gov]
  • We report on a patient with moderate hemophilia A (factor VIII:C 4-11%) who suffered from massive hematemesis, melaena and evolving shock after excessive alcohol ingestion.[ncbi.nlm.nih.gov]
  • The Mallory-Weiss syndrome is characterized by repeated bouts of retching and/or vomiting followed by the sudden onset of hematemesis or melena.[ncbi.nlm.nih.gov]
  • The most common symptoms were hematemesis (92%) and retching (61%). A history of chronic alcoholism was present in 69.5%, and recent binge drinking in 52.5% of our patients.[ncbi.nlm.nih.gov]
  • We report hematemesis from Mallory-Weiss tears after successful cardiopulmonary resuscitation (CPR). A computer search of the English language literature disclosed only 3 similar cases, and we review them.[ncbi.nlm.nih.gov]
Hiccup
  • The lesion, documented by endoscopy, appeared to follow hiccups. The bleeding responded to conservative medical management and resolved without surgical intervention.[ncbi.nlm.nih.gov]
  • Professor of Medicine, Perelman School of Medicine at The University of Pennsylvania Click here for Patient Education Mallory-Weiss syndrome is a nonpenetrating mucosal laceration of the distal esophagus and proximal stomach caused by vomiting, retching, or hiccuping[merckmanuals.com]
  • A laceration of the lower esophagus and the upper part of the stomach during forceful vomiting, retching, or hiccups is called a Mallory-Weiss tear. The tear may rupture blood vessels, which then bleed.[merckmanuals.com]
Nausea
  • Twenty-seven (41%) patients with Mallory-Weiss tear had no antecedent nausea, retching, abdominal pain or vomiting.[ncbi.nlm.nih.gov]
  • You may also be given medicine to control vomiting and nausea. Fluids may be given through an IV if you lose a large amount of blood or become dehydrated. A blood transfusion may be needed if you lose a large amount of blood.[drugs.com]
  • In women of childbearing age, the most common cause of these tears is hyperemesis gravidarum , which usually occurs in the first trimester, causing severe persistent nausea and vomiting.[emedicine.medscape.com]
  • NSAID abuse is also a rare association. [ citation needed ] In rare instances some chronic disorders like Ménière's disease that cause long term nausea and vomiting could be a factor.[en.wikipedia.org]
Melena
  • The Mallory-Weiss syndrome is characterized by repeated bouts of retching and/or vomiting followed by the sudden onset of hematemesis or melena.[ncbi.nlm.nih.gov]
  • Symptoms and Signs of Mallory Weiss Syndrome Patients usually present with hematemesis with or without melena. A history of retching, vomiting, or straining is obtained in about 50% of cases.[diseasesatoz.com]
  • Patients with Mallory-Weiss tears present with hematemesis and/or melena, and often with either epigastric or back pain.[visualdx.com]
  • This is a 68 year-old, male, who iniciated with hematemesis and melena. A few days before this episode had had chikungunya disease.[gastrointestinalatlas.com]
  • Presentation [ edit ] Mallory–Weiss syndrome often presents as an episode of vomiting up blood ( hematemesis ) after violent retching or vomiting, but may also be noticed as old blood in the stool ( melena ), and a history of retching may be absent.[en.wikipedia.org]
Chest Pain
  • Mackler's triad may be seen : Chest pain, vomiting and subcutaneous emphysema Mucosa and submucosa are involved, NOT a complete perforation.[mediconotebook.com]
  • pain , pulm orAtypical symp – Angina like chest pain , pulm or laryngeal symplaryngeal symp 9.[slideshare.net]
  • But, you may have some of these signs and symptoms: Vomit that is bright red or that looks like coffee grounds Black or tar-like stools Stools with blood present Weakness, dizziness, faintness Shortness of breath Diarrhea Paleness Abdominal or chest pain[saintlukeskc.org]
Tachycardia
  • D supine with the head of the bed flat, provide supplemental oxygen via non-rebreather mask, place him on a cardiac monitor, which shows sinus tachycardia, and obtain peripheral venous access.[journals.lww.com]
  • […] approximately 5% of all presentations of upper GI bleeds Presentation Symptoms blood in vomit blood in stool dark stools epigastric pain back pain Physical exam upper GI bleed hemodynamic instability can occur with large bleeds signs include hypotension/tachycardia[medbullets.com]
  • If epinephrine is administered, the patient needs assessment for cardiovascular complications such as hypertension or tachycardia. Sclerosants such as alcohol may be used.[medical-dictionary.thefreedictionary.com]
  • Tachycardia, hypotension, orthostatic changes, or overt shock may be evident. Diagnosis of Mallory-Weiss Tears Perform endoscopy early in the clinical course; this technique is the procedure of choice for both diagnosis and therapy of these lesions.[emedicine.medscape.com]

Workup

Whenever patients present with hematemesis, Mallory-Weiss syndrome should be suspected, particularly if vomiting or retching is also present. The diagnosis is made by physical examination, while a definite diagnosis is obtained through performing esophagogastroduodenoscopy [11], which comprises inspection of the upper GI tract with an endoscope inserted through the oral cavity and esophagus. The diagnosis is made by visualization of the mucosal tears, while a complete blood count (CBC) should be performed, to assess the severity of bleeding [12]. Hemoglobin, as well as hematocrit, should be monitored, especially in patients who reported severe hematemesis.

Left Pleural Effusion
  • pleural effusion, Mediastinal widening, Subcutaneous emphysema, Nacleiro sign [a V-shaped radiolucency seen through the heart representing air in the left lower mediastinum that dissects under the left diaphragmatic pleura] In neonatal rupture, pneumomediastinum[prep4usmle.com]
Pleural Effusion
  • effusion, Mediastinal widening, Subcutaneous emphysema, Nacleiro sign [a V-shaped radiolucency seen through the heart representing air in the left lower mediastinum that dissects under the left diaphragmatic pleura] In neonatal rupture, pneumomediastinum[prep4usmle.com]

Treatment

Mucosal tears that occur in Mallory-Weiss syndrome may spontaneously heal in mild cases, but in cases with significant blood loss and risk of recurrent bleeding, appropriate therapeutic steps must be taken [13].

Symptomatic therapy, including the administration of fluids and hydration, histamine receptor antagonists, and proton pump inhibitors [14], should be given to suppress vomiting and nausea in these patients, in order to try and minimize further aggravation of mucosal tears and bleeding. Blood transfusion is necessary only in cases of severe blood loss and markedly decreased hemoglobin values.

Endoscopic hemostasis can be performed in patients who have recurrent episodes of bleeding, usually by injection of ethanol or epinephrine onto the mucosal tears, or through electrocauterization techniques. Alternatively, systemic administration of vasopressors or angiography-guided embolization of blood vessels, principally the left gastric artery, may be necessary to control bleeding.

Endoscopic procedures, such as band ligation technique, and clipping, may be also used to reverse the bleeding from mucosal tears.

Prognosis

In the majority of the cases, bleeding from the mucosal tears is self-limited, and does not require major treatment. Patients without coexistent diseases are at the lowest risk for severe bleeding and recurrences. However, bleeding may recur, and usually occurs within 24 hours after the initial episode [8]. Recurrent bleeding phenomena are associated with risk factors such as older age, aspirin/NSAID use and presence of other comorbidities, such as chronic liver disease, chronic obstructive pulmonary disease and renal failure. These patients may require more intensive treatment and should be evaluated thoroughly, in order to prevent further complications.

Etiology

Irritation of the gastroesophageal junction and development of mucosal tears can occur as a result of any disease which causes vomiting, retching, and hiccuping:

Other factors, such as alcohol, non-steroidal anti-inflammatory drugs and esophageal instrumentation have been associated with increased risk for Mallory-Weiss syndrome. Persistent cough has also been proposed as a risk factor [5].

Epidemiology

Bleeding of the upper gastrointestinal tract is commonly seen in the hospital setting, with an incidence between 50-150 per 100,000 individuals per year, and Mallory-Weiss syndrome is responsible for about 10% of all cases of upper GI bleeding in adults [6], at the same time comprising less than 1% in children. It has been observed more commonly in men than in women, with non-specific racial predilection. Patients who present with Mallory-Weiss syndrome are usually between 30 and 50 years, and recurrent episodes of bleeding may be observed in up to 15% of cases [7].

Sex distribution
Age distribution

Pathophysiology

Mucosal lacerations of the gastroesophageal junction occur due to chronic and persistent pressure on the mucosal surfaces, which most commonly occur in vomiting, retching, or hiccuping. The pathogenesis comprises sudden increases in intragastric pressure, as well as distension, which leads to forceful ejection of acidic content of the stomach and damage to the mucosal surfaces. Additionally, significant changes in pressure along the gastric wall also contribute to the development of these tears, because distortion of the gastric cardia occurs as a result of changes in intrathoracic and intragastric pressures. The most prominent risk factor is the presence of a hiatal hernia, which is quite commonly observed in patients who develop mucosal tears, while other underlying conditions, such as portal hypertension (which may lead to the development of esophageal varices), and liver failure have also been implicated in the pathogenesis of this condition.

Once the mucosal tears are formed, they can become a source of bleeding if further aggravated, which is why it is imperative to promptly obtain a diagnosis of this condition.

Prevention

Prevention of Mallory-Weiss syndrome does not encompass specific measures because mucosal tears at the gastroesophageal junction may occur without history of prior illnesses and may be asymptomatic. Nevertheless, an early diagnosis may allow for better monitoring of the disease and patients with unexplained retching, vomiting and hiccuping should immediately report these complaints to a physician, because an early diagnosis may prevent complications such as severe or recurrent bleeding. Patients with a hiatal hernia and other associated risk factors should be treated accordingly, in order to prevent the development of mucosal tears. Alcohol should be avoided, because it can cause deal damage directly to the mucosa through its effects, or indirectly, through liver intoxication and development of liver cirrhosis, which leads to portal hypertension, another risk factor for the development of mucosal tears.

Summary

Mallory-Weiss syndrome demarcates a nontransmural mucosal laceration (tear) of the esophagus and the stomach at the gastroesophageal junction. The majority of patients develop a single tear, while almost 20% of individuals develop two or more tears [1]. These tears develop as a result of persistent and chronic injury to the esophagus, which can be caused by prolonged retching, vomiting, or hiccuping, usually from an underlying gastrointestinal or hepatobiliary disease, but this syndrome may appear in a range of other conditions as well. Initially, alcoholic binge drinking was established as the main risk factor for the development of mucosal tears [2], but they have been observed and diagnosed in many non-alcoholic patients, with some other diseases as predisposing conditions. Other risk factors, such as the presence of a hiatal hernia and dyspepsia have been established, while women suffering from hyperemesis gravidarum during pregnancy are also prone to developing Mallory-Weiss syndrome. Mucosal tears at the gastroesophageal junction most likely occur because of sudden changes in intragastric pressure (i.e vomiting, retching), or it may occur as a result of rapid changes in the pressure across the gastric wall, as well as a result of reflux of acidic content from the stomach. 

This syndrome is most commonly encountered among adults, while its occurrence among the pediatric population is rare. The typical presentation of Mallory-Weiss syndrome includes hematemesis, melena, and sometimes involuntary retching and abdominal pain. The diagnosis is made clinically and is confirmed by performing esophagogastroduodenoscopy, to allow for direct visualization of the gastroesophageal junction and identification of the source of bleeding. Treatment consists of stabilizing the patient, since it is not uncommon for patients to vomit large amounts of blood, which may lead to hypotension and shock. Cessation of bleeding should also be accomplished through different techniques. Treatment of the underlying cause is mandatory, in order to prevent other complications.

Patient Information

Mallory-Weiss syndrome is a disease which involves tears in the lining of the esophagus at the site of the junction with the stomach and it most commonly occurs after persistent and severe vomiting, retching, hiccuping and coughing as well. There are numerous diseases in which vomiting may be a symptom, including food poisoning, peptic ulcer disease, hepatitis, anorexia, bulimia, vomiting during pregnancy, and many other which make individuals prone to developing these esophageal tears. It is most commonly observed in adults, while children rarely develop this syndrome. Men are more frequently affected than women.

Mallory-Weiss syndrome usually presents with vomiting of blood, which can be accompanied by abdominal pain and black stools. Vomiting of blood may be mild, or it may be severe enough to require intravenous hydration and blood transfusion. For these reasons, all patients who have vomiting of blood as a symptom are thoroughly evaluated, in order to identify the cause and source of bleeding, as it may be life-threatening. In most cases, a procedure called esophagogastroduodenoscopy will be performed, which consists of inserting a tube into the esophagus through the oral cavity that contains a camera at its end and inspects the esophagus and the stomach. The location and source of bleeding may be visualized and the diagnosis of Mallory-Weiss syndrome can be made.

After the diagnosis is made, patients are usually treated based on the severity of bleeding. Therapy includes medications to suppress vomiting and gastrointestinal disturbance, but also hydration and, in severe cases, blood transfusions. Cauterization (burning of tissue to stop the bleeding) and injection of certain agents that cause constriction of blood vessels are also an option. Surgery is rarely performed, and is reserved for those with severe and recurrent bleeding which does not resolve with adequate treatment.

References

Article

  1. Sugawa C, Benishek D, Walt AJ. Mallory-Weiss syndrome: a study of 224 patients. Am J Surg. 1983;145:30-33.
  2. Mallory GK, Weiss S. Hemorrhages from lacerations of the cardiac orifice of the stomach due to vomiting. Am J Med Sci. 1929;178:506.
  3. Gowen GF, Stoldt HS, Rosato FE. Five risk factors identify patients with gastroesophageal intussusception. Arch Surg. 1999;134:1394-1397.
  4. Michel L, Serrano A, Malt RA. Mallory-Weiss syndrome: evolution of diagnostic and therapeutic patterns over two decades. Ann Surg. 1980; 192:716-721.
  5. Annunziata GM, Gunasekaran TS, Berman JH, et al. Cough-induced Mallory-Weiss tear in a child. Clin Pediatr (Phila). 1996;35:417-419.
  6. Akhtar AJ, Padda MS. Natural history of Mallory-Weiss tear in African American and Hispanic patients. J Natl Med Assoc. 2011;103:412-415.
  7. Kim JW, Kim HS, Byun JW, et al. Predictive factors of recurrent bleeding in Mallory-Weiss syndrome. Korean J Gastroenterol. 2005;46:447-454.
  8. Bharucha AE, Goustout CJ, Balm RK. Clinical and endoscopic risk factors in the Mallory-Weiss syndrome. Am J Gastroenterol. 1997;92:805-808.
  9. Yu PP, White D, Iannuccilli EA. The Mallory-Weiss syndrome in the pediatric population. Rare condition in children should be considered in the presence of hematemesis. R I Med J. 1982;65(2):73-4.
  10. Graham DY, Schwartz JT. The spectrum of the Mallory-Weiss tear. Medicine (Baltimore). 1978;57:307-318.
  11. Ament ME, Gans L, Christie DK. Experience with esophagogastro-duodenoscopy in diagnosis of 79 pediatric patients with hematemesis, melena or chronic abdominal pain. Gastroenterology. 1975;68:858-61.
  12. Fujisawa N, Inamori M, Sekino Y, et al. Risk factors for mortality in patients with Mallory-Weiss syndrome. Hepatogastroenterology. 2011;58:417-20.
  13. Hastings PR, Peters KW, Cohn I Jr. Mallory-Weiss syndrome: review of 69 cases. Am J Surg. 1981;142:560-562.
  14. Barkun AN, Bardou M, Kuipers EJ, et al; International consensus Upper Gastrointestinal Bleeding Conference Group. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Internal Med. 2010;152:101-113.

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Last updated: 2018-06-22 00:40