MALLORY-WEISS SYNDROME

Mild to massive and usually painless bleeding due to a tear in the mucosa or submucosa of the
cardia or lower esophagus characterizes Mallory-Weiss syndrome. Such a tear, usually singular
and longitudinal, results from prolonged or forceful vomiting. About 60% of these tears involve
the cardia; 15%, the terminal esophagus; and 25%, the region across the esophagogastric
junction. Mallory-Weiss syndrome is most common in men older than age 40, especially
alcoholics.
Causes
The direct cause of a tear in Mallory-Weiss syndrome is forceful or prolonged vomiting,
probably when the upper esophageal sphincter fails to relax during vomiting. This lack of
sphincter coordination is more common after excessive intake of alcohol. Other factors and
conditions that may also increase intra-abdominal pressure and predispose to esophageal tearing
include coughing, straining during bowel movements, trauma, seizures, childbirth, hiatal hernia,
esophagitis, gastritis, and atrophic gastric mucosa.
CLINICAL TIP Patients with portal hypertension are at a higher risk for continuous or
recurerrent bleeding. Monitoring for signs of hemorrhage is advised.
Signs and symptoms
Typically, Mallory-Weiss syndrome begins with the vomiting of blood or the passing of large
amounts of blood rectally a few hours to several days after normal vomiting. This bleeding,
which may be accompanied by epigastric or back pain, may range from mild to massive but is
generally more profuse than in esophageal rupture.
In patients with Mallory-Weiss syndrome, the blood vessels are only partially severed,
preventing retraction and closure of the lumen. Massive bleeding most likely when the tear is
on the gastric side, near the cardia may quickly lead to fatal shock.

Diagnosis
Identifying esophageal tears by fiberoptic endoscopy confirms Mallory-Weiss syndrome. These
lesions, which usually occur near the gastroesophageal junction, appear as erythematous
longitudinal cracks in the mucosa when recently produced and as raised, white streaks
surrounded by erythema when older. Other helpful diagnostic measures include the following:
* Angiography (selective celiac arteriography) can determine the bleeding site but not the cause;
this is used when endoscopy isnt available.
* Gastrotomy may be performed at the time surgery
* Hematocrit helps quantify blood loss.
Treatment
Appropriate treatment varies with the severity of bleeding. Usually, GI bleeding stops
spontaneously, requiring supportive measures and careful observation but no definitive
treatment. However, if bleeding continues, treatment may include:
Angiographic infusion of a vasoconstrictor (vasopressin) into the superior mesenteric artery or
direct infusion into a vessel that leads to the bleeding artery.
Transcatheter embolization or thrombus formation with an autologous blood clot or other
hemostatic material (insertion of artificial material, such as a shredded absorbable gelatin sponge
or, less commonly, the patients own clotted blood through a catheter into the bleeding vessel to
aid thrombus formation).
Surgery to suture each laceration (for massive recurrent or uncontrollable bleeding).
Special considerations

Evaluate respiratory status, monitor arterial blood gas measurements, and administer oxygen as
necessary.
Assess the amount of blood loss, and record related signs, such as hematemesis and melena
(including color, amount, consistency, and frequency).
Monitor hematologic status (hemoglobin level, hematocrit, red blood cell count). Draw blood for
coagulation studies (prothrombin time, partial thrombloplastin time, and platelet count) and
typing and crossmatching.
Try to keep three units of matched whole blood on hand at all times. Until blood is available,
insert a large-bore (14G to 18G) I.V. line, and start a temporary infusion of normal saline
solution.
Monitor the patients vital signs, central venous pressure, urine output, and overall clinical status.
Avoid giving the patient medications that may cause nausea or vomiting. Administer an
antiemetic, as necessary, to prevent postoperative retching and vomiting.
Advise the patient to avoid alcohol, aspirin, and other irritating substances.
Taken from Handbook of DISEASES Third Edition, Lippincott Williams & Wilkins