Mallory-Weiss syndrome

Mallory-Weiss Syndrome

Definition

Mallory-Weiss syndrome is bleeding from an arterial blood vessel in the upper gastrointestinal tract, caused by a mucosal gastric tear at or near the point where the esophagus and stomach join.

Description

Mallory-Weiss syndrome causes about 5% of all upper gastrointestinal bleeding. The condition was originally diagnosed in alcoholics and is associated with heavy alcohol use, although it can also be found in patients who are not alcoholics. Earlier episodes of heavy hiccupping, vomiting, and retching are reported by about half the patients who are diagnosed with Mallory-Weiss syndrome. It is thought that the tear or laceration occurs when there is a sudden increase in intra-abdominal pressure. Patients with increased pressure in the vein leading into the liver (portal hypertension) are more likely to bleed heavily from an esophageal laceration than those whose blood pressure is normal.

Causes and symptoms

In Mallory-Weiss syndrome, a tear occurs in the gastric mucosa, near where the esophagus and stomach join. About 10% of the tears are in the esophagus. Most are either right at the junction of the esophagus and stomach or in the stomach just slightly below the junction.Bleeding from the tear causes a disruption in fluid and electrolyte balance of the body. The patient often produces vomit tinged with either fresh blood or older, blackish blood. Blood loss can be considerable.

Diagnosis

A Mallory-Weiss syndrome tear is not visible on standard upper gastrointestinal x rays. A tear about one-eighth to one and one-half inches long (0.5-4 cm) is revealed by endoscopy. Endoscopy also shows that in 35% of patients there is another potential cause for gastrointestinal bleeding, such as peptic ulcer, erosive gastritis, or esophageal varices.

Treatment

The patient is resuscitated and stabilized with blood transfusions and intravenous fluids to restore the fluid and electrolyte balance. Most of the time, esophageal bleeding stops spontaneously. When bleeding does not stop, patients are treated with an injection of epinephrine (adrenaline) and/or the bleeding artery is cauterized with heat. If these treatments fail, surgery is performed to stop the bleeding.

Prognosis

In 90-95% of patients whose bleeding does not stop spontaneously, cauterization without surgery will stop the bleeding. Patients at highest risk for a recurrence of bleeding are those with portal hypertension.

Prevention

Mallory-Weiss syndrome is associated with alcoholism. Limiting alcohol intake may help prevent the disorder.

Resources

Books

"Mallory-Weiss Syndrome." In Current Medical Diagnosis and Treatment, 1998. edited by Stephen McPhee, et al., 37th ed. Stamford: Appleton & Lange, 1997.

Key terms

Electrolytes — Salts and minerals that can conduct electrical impulses in the body. Common human electrolytes are sodium chloride, potassium, calcium, and sodium bicarbonate. Electrolytes control the fluid balance of the body and are important in muscle contraction, energy generation, and almost every major biochemical reaction in the body.Endoscopy — A procedure in which an instrument containing a camera and a light source is inserted into the gastrointestinal tract so that the doctor can visually inspect the gastrointestinal system.Esophageal varix — An enlarged vein of the esophagus. (Plural: esophageal varices.)Portal hypertension — High blood pressure in the portal vein, which carries blood from the abdominal organs to the liver.

Mal·lo·ry-Weiss syn·drome

(mal'ŏ-rē wīs), upper gastrointestinal hemorrhage resulting from a laceration in the mucosa at the gastroesophageal junction, usually induced by retching or vomiting. Synonym(s): Mallory-Weiss lesion, Mallory-Weiss tear

Mallory-Weiss syndrome

Upper GI bleeding linked to longitudinal mucosal lacerations at the oesophagogastric junction or gastric cardia, which accounts for 5–15% of upper GI bleeds. While the original report by Mallory and Weiss in 1929 involved alcoholics with persistent retching and vomiting, the syndrome may follow any event that provokes a sudden rise in intragastric pressure or gastric prolapse into the oesophagus.
Clinical findings
The classic presentation is vomiting, retching or violent coughing, usually (85%) accompanied by haematemesis.

Risk factors
Hiatal hernia (35–100% of patients); alcohol use is reported in 40–75%, aspirin in 30%.
Management
Bleeding stops spontaneously in 80–90% of patients; most require symptomatic relief; active management strategies include bipolar electrocoagulation by endoscopy, injection therapy, transcatheter embolisation, and intra-arterial vasopressin infusion.

Mal·lo·ry-Weiss syn·drome

(mal'ŏr-ē wīs sin'drōm) Laceration of the lower end of the esophagus associated with bleeding or penetration into the mediastinum, with subsequent mediastinitis; usually caused by severe retching and vomiting.

Mallory-Weiss syndrome

A tear at the lower end of the gullet (OESOPHAGUS) caused by violent movements of the DIAPHRAGM during retching or vomiting. There is vomiting of blood. In most cases the tear heals well, often without treatment. (George Kenneth Mallory, b. 1900, American pathologist; and Konrad Weiss, 1898–1942, American physician).

Mallory-Weiss Syndrome

DRG Category:	326
Mean LOS:	15.4 days
Description:	SURGICAL: Stomach, Esophageal, and Duodenal Procedure With Major CC
DRG Category:	378
Mean LOS:	4 days
Description:	MEDICAL: Gastrointestinal Hemorrhage With CC

Mallory-Weiss syndrome (MWS) is a tear or laceration, usually singular and longitudinal, in the mucosa at the junction of the distal esophagus and proximal stomach. Esophageal lacerations account for between 5% and 10% of upper gastrointestinal (GI) bleeding episodes. Approximately 60% of the tears involve the cardia, the upper opening of the stomach that connects with the esophagus. Another 15% involve the terminal esophagus, and 25% involve the region across the epigastric junction. In a small percentage of patients, the tear leads to upper GI bleeding. Most episodes of bleeding stop spontaneously, but some patients require medical intervention. If bleeding is excessive, hypovolemia and shock may result. Esophageal rupture (Boerhaave’s syndrome) is rare but catastrophic when it does occur. If esophageal perforation occurs, the patient may develop abscesses or sepsis.

Causes

The most common cause of MWS is failure of the upper esophageal sphincter to relax during prolonged vomiting. This poor sphincter control is more likely to occur after excessive intake of alcohol. Any event that increases intra-abdominal pressure can also lead to an esophageal tear, such as persistent forceful coughing, trauma, seizure, pushing during childbirth, or a hiatal hernia. Other factors that may predispose a person to MWS are esophagitis, gastritis, and atrophic gastric mucosa. Tears may occur in children with predisposing liver conditions such as cirrhosis or portal hypertension.

Genetic considerations

MWS is not currently thought to have a genetic association, although it has been seen in identical twins.

Gender, ethnic/racial, and life span considerations

Mallory-Weiss syndrome, first described in people with alcohol dependence, is now recognized across the life span. The incidence is approximately equal between males and females in both childhood and adulthood. In women, hyperemesis gravidarum in the first trimester of pregnancy causes persistent nausea and vomiting, which may lead to MWS. Adolescents with MWS should be evaluated for eating disorders or alcohol and drug use. There are no known ethnic or racial considerations.

Global health considerations

The global incidence of MWS is likely similar to that in the United States, where Mallory-Weiss tears account for up to 15% of people who have upper GI bleeding. Data from developing regions of the world are not available.

Assessment

History

The patient may report a history of retching and vomiting, followed by vomiting bright red blood. Ask the patient about the appearance of the vomitus. Hematemesis has a “coffee-ground” appearance if it is of gastric origin and is often a sign of brisk bleeding, usually from an arterial source or esophageal varices. Ask about passage of blood with bowel movements, either a few hours to several days after vomiting. Although vomiting and retching before the onset of bleeding can be indicative of a Mallory-Weiss tear, some patients with MWS do not present with such a history. Inquire about weakness, fatigue, and dizziness, any and all of which can result with chronic blood loss. Ask about a history of alcoholism, hiatal hernia, seizures, or a recent severe cough.

Physical examination

Inspect the patient’s nasopharynx to rule out the nose and throat as the source of bleeding. Assess the patient for evidence of trauma to the head, chest, and abdomen as well. Note that manifestations of GI bleeding depend on the source of bleeding, the rate of bleeding, and the underlying or coexisting diseases. Patients with massive bleeding have the clinical signs of shock, such as a heart rate greater than 110 beats per minute, an orthostatic blood pressure drop of 16 mm Hg or more, restlessness, decreased urine output, and delayed capillary refill.

Psychosocial

The sudden admission to an acute care facility for GI bleeding is stressful and upsetting. Assess the patient’s anxiety level, along with his or her understanding of the treatment and intervention plan. Because MWS is associated with alcohol use and abuse, determine if the patient is a problem drinker and assess the family’s and significant others’ responses to the patient’s drinking.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Fiberoptic endoscopy (esophagogastroduodenoscopy)	Visualization of normal tissue	Mucosal tear at gastroesophageal junction	Small fiberoptic tube is inserted into the esophagus to permit visual inspection and is the best procedure to use both for diagnosis and treatment
Complete blood count	Red blood cells (RBCs): 4–5.5 million/μL; white blood cells: 4,500–11,000/μL; hemoglobin (Hgb): 12–18 g/dL; hematocrit (Hct): 37%–54%; reticulocyte count: 0.5%–2.5% of total RBCs; platelets: 150,000–400,000/μL	Decreased RBCs, Hgb, and Hct because of upper GI bleeding	Serial monitoring to monitor the extent of blood loss; assesses the response to therapy

Other Tests: Arteriography, coagulation studies. Generally, barium or other contrast media such as Gastrografin should be not be done because they are not sensitive to Mallory-Weiss tears, and they may interfere with other diagnostic tests such as endoscopy.

Primary nursing diagnosis

Diagnosis

Airway clearance, ineffective, related to aspiration of blood

Outcomes

Respiratory status: Gas exchange and ventilation; Safety status: Physical injury

Interventions

Airway insertion; Airway management; Airway suctioning; Oral health promotion; Respiratory monitoring; Ventilation assistance; Surveillance; Respiratory monitoring; Anxiety reduction

Planning and implementation

Collaborative

Bleeding often subsides spontaneously in almost 75% of patients. If bleeding has not stopped, generally treatment is completed during the endoscopy examination. Several choices are available for treating a bleeding tear. Endoscopic band ligation has been shown to be the most effective treatment for severe, active bleeding. Active bleeding may be treated with electrocoagulation or heater probe with or without epinephrine injection to stop bleeding. If epinephrine is administered, the patient needs assessment for cardiovascular complications such as hypertension or tachycardia. Sclerosants such as alcohol may be used. Endoscopic hemoclipping may also be effective for Mallory-Weiss tears, or the patient may need to go to surgery to have the tear oversewn. Generally, the use of balloon tamponade with a Sengstaken-Blakemore or Minnesota tube is no longer considered an effective treatment because it may further widen the tear. For severe cases, embolization of the left gastric artery may be used.

If the patient has excessive blood loss, institute strategies to support the circulation. To stabilize the circulation and replace vascular volume, place a large-bore (14- to 18-gauge) intravenous catheter and maintain replacement fluids, such as 0.9% sodium chloride, and blood component therapy as prescribed. With continued or massive bleeding, the patient may be supported with blood transfusions and admitted to an intensive care unit for close observation.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Epinephrine	1:10,000–1:20,000 dilution injected in small amounts around and into the bleeding point	Catecholamine	To halt bleeding by vasoconstriction
Vasopressin	Titrate to produce the desired clinical outcome	Vasoconstrictor	To halt bleeding by vasoconstriction

Except for epinephrine, which is sometimes used during endoscopy, no medications are used to manage MWS directly. Patients may be placed on antacids, sucralfate (Carafate), or histamine2 blockers, proton pump inhibitors such as omeprazole (Prilosec), or antiemetics such as prochlorperazine (Compazine) to reduce nausea and vomiting. In unusual cases of severe hemorrhage, patients may be placed on vasopressin to reduce upper GI bleeding, and fluid resuscitation and vasopressors may be used to support the circulation.

Independent

A major cause of morbidity and mortality in patients with active GI bleeding is aspiration of blood with subsequent respiratory compromise, which is seen in patients with inadequate gag reflexes or those who are unconscious or obtunded. Constant surveillance to ensure a patent airway is essential. Check every 8 hours for the presence of a gag reflex. Maintain the head of the bed in a semi-Fowler’s position unless contraindicated. If the patient needs to be positioned with the head of the bed flat, place the patient in a side-lying position.

Encourage bedrest and reduced physical activity to limit oxygen consumption. Plan care around frequent rest periods, scheduling procedures so the patient does not overtire. Avoid the presence of noxious stimuli that may be nauseating. Support nutrition by eliminating foods and fluids that cause gastroesophageal discomfort. Encourage the patient to avoid caffeinated beverages, alcohol, carbonated drinks, and extremely hot or cold food or fluids. Help the patient understand the treatments and procedures. Provide information that is consistent with the patient’s educational level and that takes into account the patient’s state of anxiety.

Evidence-Based Practice and Health Policy

Kriengkirakul, C. (2010). T1583: Mallory-Weiss syndrome: Who needs endoscopic treatment? Gastrointestinal Endoscopy, 71(5), AB314–AB315. doi 10.1016/j.gie.2010.03.797

Treatment with endoscopy is typically required for excessive gastrointestinal bleeding related to MWS. In a prospective study among 112 patients with MWS, endoscopic treatment was required by 40.2% of patients.
Patients with a platelet count less than 100,000/uL had a 3.4 times increased odds of needing endoscopic treatment (95% CI, 1.2 to 9.8; p < 0.05) when compared to patients with a platelet count above 100,000/uL. Seventy percent of patients required a median of two units of blood via transfusion. There were no bleeding-related deaths; however, six patients died from sepsis.
In this sample, 24% had underlying conditions, which included cirrhosis (85%), end-stage renal disease (7.4%), alcoholic hepatitis (3.7%), and chronic myeloid leukemia (3.7%).

Documentation guidelines

Physical response: Frequency and amount of hematemesis; laboratory values of interest; presence of blood in the stool; degree of discomfort (location, duration, precipitating factors)
Response to treatments: Success of interventions to stop bleeding; response to fluids and blood component therapy; function of tamponade tubes; ability to maintain rest and conserve energy
Ability to tolerate food and fluids; nausea and vomiting

Discharge and home healthcare guidelines

Teach the patient to avoid foods and fluids that cause discomfort or irritation. Determine the patient’s understanding of any prescribed medications, including dosage, route, action or effect, and side effects. Review signs and symptoms of recurrent bleeding and the need to seek immediate medical care. Provide a phone number for the patient to use if complications develop.

Mallory,

George Kenneth, U.S. pathologist, 1900–. Mallory syndrome - gastroesophageal junction mucosal laceration.Mallory-Weiss lesion - laceration of the gastric cardia, as seen in the Mallory-Weiss syndrome. Synonym(s): Mallory-Weiss tearMallory-Weiss syndrome - laceration of the lower end of the esophagus, associated with bleeding, caused usually by severe retching and vomiting.Mallory-Weiss tear - Synonym(s): Mallory-Weiss lesion

Weiss,

Soma, U.S. physician, 1898-1942. Charcot-Weiss-Baker syndrome - see under CharcotMallory-Weiss lesion - see under Mallory, George KennethMallory-Weiss syndrome - see under Mallory, George KennethMallory-Weiss tear - Synonym(s): Mallory-Weiss lesion