Mallory-Weiss Syndrome

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Mallory-Weiss syndrome (MWS) is characterised by upper gastrointestinal bleeding (UGIB) from mucosal lacerations in the upper gastrointestinal tract (GIT) (usually at the gastro-oesophageal junction or gastric cardia). Mallory and Weiss described the syndrome in 1929 in patients retching and vomiting after an alcoholic binge.

MWS may also occur with other events, causing a sudden rise in intragastric pressure or gastric prolapse into the oesophagus. Sudden increased pressure within the nondistensible lower oesophagus causes tearing. It is a feature of about 10% (ranging from 1% to 15%) of upper gastrointestinal bleeds and causes significant hypovolaemia in about 10% of these. There appears to be a trend towards less associated blood loss and lower mortality. It is often associated with hiatus hernia and is also associated with alcoholism and dialysis.

In recent years, MWS may have become more frequent.[1]

  • The incidence of UGIB is between 47 and 116 per 100,000 population (mostly from ulcers).[2]
  • Mallory-Weiss tears cause approximately 3-15% of all episodes of haematemesis in adults. Tears can occur in children but are less common.[3]
  • There is a wide age range. It is most common between age 40 and 50 years.

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Causes

  • Excessive alcohol ingestion.
  • Aspirin ingestion.
  • Hiatus hernia is a predisposing factor. During retching or vomiting, the transmural pressure gradient is greater within the hiatus hernia than the rest of the stomach.
  • Other precipitating factors include retching, vomiting, straining, hiccuping, coughing, blunt abdominal trauma and cardiopulmonary resuscitation.
  • Other gastrointestinal diseases (gastroenteritis, gastric outlet obstruction, malrotation, volvulus).
  • Hyperemesis gravidarum.[4]
  • Hepatitis (causes vomiting in 10-20% of patients).
  • Biliary disease (gallstones and cholecystitis).
  • Renal disease - vomiting is often associated with diseases affecting the kidneys (from urinary tract infections to renal failure).
  • Raised intracranial pressure may lead to vomiting (particularly in children).
  • Cyclical vomiting syndrome.
  • Other causes include drugs, and severe diabetic ketoacidosis.
  • Iatrogenic tears are uncommon, even with a high incidence of retching during endoscopy. The reported prevalence is 0.07-0.49%. It has also been reported in transoesophageal echocardiography.[5]
  • No apparent precipitating factor can be identified in about 25% of patients.

History

  • The classic presentation is of haematemesis following a bout of retching or vomiting. However, a tear may occur after a single vomit.[3]
  • Other symptoms include melaena, light-headedness, dizziness, or syncope, and features associated with the initial cause of the vomiting, eg abdominal pain.

Examination

  • There are no specific physical signs.
  • An assessment of the degree of blood loss should be made. The Rockall scoring system can be used to assess UGIB.[6] A score of less than 3 is associated with an excellent prognosis and 8 or above an extremely poor prognosis. MWS is usually associated with a score of 3 or less.

Haematemesis as a symptom has quite a long differential diagnosis. The following are important to consider (particularly with the retching and sudden bright bleeding associated with MWS):

Endoscopy is the primary diagnostic investigation. Other relevant investigations include:

  • FBC, including haematocrit to assess the severity of the initial bleeding episode and to monitor patients.
  • Coagulation studies and platelet counts to detect coagulopathies and thrombocytopenias (routine platelet count, prothrombin time, and activated partial thromboplastin time).
  • Renal function, urea, creatinine, and electrolyte levels (to guide intravenous fluid therapy).
  • Cross-matching/ blood grouping and antibody screen (potential blood transfusion).
  • Electrocardiogram and cardiac enzymes (may be indicated if myocardial ischaemia is suspected).

Initial management is described in the separate article Upper gastrointestinal bleeding (includes Rockall Score).

Initial assessment and management

  • Resuscitation is a priority - maintain airway, provide high-flow oxygen, correct fluid losses (place two wide-bore cannulae and also send bloods at the same time). Initial fluid resuscitation may be with crystalloids or colloids; give intravenous blood when 30% of circulating volume is lost.[8] Major haemorrhage protocols should be in place.[8]
  • Once the patient is more stable - take a history and perform an examination (as 'Examination', above); identify severity of blood loss and treat any comorbid conditions.
  • MWS usually follows a benign course but occasionally endoscopic treatment is required to stop bleeding. Sclerotherapy, electrocoagulation and nd:YAG laser treatment can all be used to arrest bleeding. Banding and clipping techniques have also been used.[9]

Endoscopy[8]

  • Ideally, endoscopy should be performed within 24 hours, as tears heal rapidly and may not be readily apparent at endoscopy after 2-3 days. Proton pump inhibitor (PPI) use is not recommended prior to diagnosis by endoscopy.
  • 5-35% of patients require some form of intervention, usually endoscopic.
  • Most patients (>80%) present with a single tear. The tear is usually just below the gastro-oesophageal junction on the lesser curvature of the stomach.
  • Tears are usually associated with other mucosal lesions (83% of patients). These may contribute to bleeding and/or cause the retching and vomiting. Endoscopic examination should be thorough because such co-existing lesions are common.
  • Several endoscopic modalities are effective for treating a bleeding Mallory-Weiss tear. Injection therapy is often regarded as the first-line therapy.[3]
  • Fasting is restricted to haemodynamically unstable patients and to those who require repeat endoscopy.
  • Patients can resume oral intake following endoscopy (starting with a liquid diet and advancing as tolerated to a normal diet) within 48 hours (unless nausea or vomiting is a problem).

Post-initial endoscopy[8]

Calculate the full (post-endoscopic) Rockall Score, as described in the Upper gastrointestinal bleeding (includes Rockall Score) separate article - score <3 is associated with low risk of re-bleeding or death and can be considered for early discharge, whereas a score >3 indicates patients need further close observation as an inpatient.

  • Careful monitoring is needed after endoscopy for UGIB (pulse, blood pressure, urine output). It is imperative to identify re-bleeding or continuing bleeding.
  • Patients with clinical risk factors for re-bleeding (for example, portal hypertension, coagulopathy) comprise about 10% of cases. These and those with certain endoscopic findings (non-bleeding visible vessel, pigmented protuberance, or adherent clot) should be observed for 48 hours.
  • If patients are stable 4-6 hours after endoscopy they should be put on a light diet, as there is no benefit in continued fasting.
  • If re-bleeding occurs, it usually takes place within 48 hours. Shock at initial manifestation and active bleeding at endoscopy are independent risk factors predicting recurrent bleeding in patients with MWS.[3]

These relate to:

  • Symptoms:
  • Severity of bleeding:
    • Hypovolaemic shock, and death (very rare with good care).
    • Myocardial ischaemia or infarction.
  • Comorbidities:
    • Myocardial ischaemia (precipitating, for example, myocardial infarction).
    • Hepatitis (precipitating, for example, liver failure).
    • Renal disease (precipitating, for example, renal failure).
    • Diabetes (worsening control and diabetic coma).
  • Treatment or investigation:
    • Endoscopy (mediastinitis, aspiration pneumonia, perforation or aggravation of bleeding).
    • Angiotherapy (organ ischaemia and infarction, aggravation of bleeding).
  • The prognosis is generally excellent. Most patients usually stop bleeding spontaneously and the tears heal rapidly, usually within 48-72 hours.
  • However, bleeding is variable and can range from a few specks or streaks of blood mixed with mucus to large amounts of fresh blood. Shock occurs in adults in as many as 20% but is much less common in children.[3]
  • Associated diseases may have a significant effect on prognosis; for example, cirrhosis carries a very poor prognosis.[10]

Recurrence is rare but it makes sense to counsel patients about precipitating factors (for example, binge drinking, alcohol consumption, excessive straining and lifting, violent coughing) that may lead to a recurrence and are generally hazardous to health. Risk factors for recurrent bleeding include:[3]

  • Initial presentation of shock.
  • Liver cirrhosis.
  • Decreased haemoglobin and platelet count.
  • Need for blood transfusion.
  • Intensive care management.
  • Active bleeding noted at the time of endoscopy.

Further reading & references

  1. Henrion J, Schapira M, Ghilain JM, et al; Upper gastrointestinal bleeding: What has changed during the last 20 years? Gastroenterol Clin Biol. 2008 Sep 9.
  2. Enestvedt BK, Gralnek IM, Mattek N, et al; An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium. Gastrointest Endosc. 2008 Mar;67(3):422-9. Epub 2008 Jan 18.
  3. Cuffari C, Mallory-Weiss Syndrome, Medscape, Mar 2010
  4. Ismail SK, Kenny L; Review on hyperemesis gravidarum. Best Pract Res Clin Gastroenterol. 2007;21(5):755-69.
  5. Fujii H, Suehiro S, Shibata T, et al; Mallory - weiss tear complicating intraoperative transesophageal echocardiography. Circ J. 2003 Apr;67(4):357-8.
  6. Acute upper GI bleeding, NICE Clinical Guideline (June 2012)
  7. Lewis AM, Dharmarajah R; Walked in with Boerhaave's.... Emerg Med J. 2007 Apr;24(4):e24.
  8. Management of acute upper and lower gastrointestinal bleeding; Scottish Intercollegiate Guidelines Network - SIGN (September 2008)
  9. Cho YS, Chae HS, Kim HK, et al; Endoscopic band ligation and endoscopic hemoclip placement for patients with Mallory-Weiss syndrome and active bleeding. World J Gastroenterol. 2008 Apr 7;14(13):2080-4.
  10. Schemmer P, Decker F, Dei-Anane G, et al; The vital threat of an upper gastrointestinal bleeding: Risk factor analysis of 121 consecutive patients. World J Gastroenterol. 2006 Jun 14;12(22):3597-601.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Richard Draper
Current Version:
Peer Reviewer:
Dr Adrian Bonsall
Last Checked:
19/07/2012
Document ID:
2421 (v22)
© EMIS