From the Guidelines
Healthcare providers should prioritize endoscopic therapy as the first-line treatment for Mallory-Weiss syndrome, with proton pump inhibitors administered to reduce gastric acid and stabilize clots, as most cases resolve spontaneously or with minimal intervention, and only rare cases require more invasive procedures like angiographic embolization or surgery. Mallory-Weiss syndrome is a condition characterized by longitudinal mucosal lacerations at the gastroesophageal junction, typically caused by forceful vomiting or retching, as seen in a case where a patient presented with sudden haematemesis followed by melena after percutaneous coronary intervention (PCI) 1. Healthcare providers should recognize that patients often present with hematemesis following episodes of vomiting, retching, or coughing.
Key Points for Management
- Most cases (80-90%) resolve spontaneously without specific intervention, requiring only supportive care including IV fluids, correction of coagulopathies, and monitoring.
- For ongoing bleeding, endoscopic therapy is the first-line treatment, with options including epinephrine injection (1:10,000 solution), thermal coagulation, or mechanical methods like hemoclips.
- Proton pump inhibitors (such as pantoprazole 40mg IV twice daily) should be administered to reduce gastric acid and stabilize clots, as indicated for the prevention of rebleeding from Mallory-Weiss tears 1.
- In rare cases of persistent bleeding despite endoscopic therapy, angiographic embolization or surgical intervention may be necessary.
Risk Factors and Pathophysiology
- Risk factors providers should note include alcoholism, hiatal hernia, portal hypertension, and coagulopathies.
- The pathophysiology involves a sudden increase in intra-abdominal pressure against a closed glottis, causing a tear at the gastroesophageal junction where the circular esophageal muscles transition to the longitudinal gastric muscles, creating a vulnerable point for mucosal injury. Some studies have highlighted the importance of prompt recognition and treatment of Mallory-Weiss syndrome to prevent complications, as seen in a case where a patient developed pulseless ventricular tachycardia after skipping clopidogrel maintenance doses 1. However, the most recent and highest quality study on the topic of proton pump inhibitor use, which includes indications for Mallory-Weiss syndrome, is from 2022 1.
From the Research
Definition and Causes of Mallory-Weiss Syndrome
- Mallory-Weiss syndrome is a cause of upper gastrointestinal bleeding, accounting for 3-15% of all cases 2.
- The syndrome is characterized by a tear near the esophagogastric mucosal junction, often induced by an abrupt rise in abdominal pressure due to nausea or vomiting 2.
- The tear is mainly located on the cardia part of the stomach side and can span across the esophagogastric mucosal junction 2.
Diagnosis and Treatment
- Diagnosis is typically made using upper gastrointestinal endoscopy, which should be performed rapidly after the first hematemesis 3.
- Endoscopic findings may reveal a longitudinal mucosal tear at the esophagogastric junction, and patients with active bleeding or signs of recent bleeding may require immediate endoscopic treatment for hemostasis 3.
- Treatment options include endoscopic hemostatic techniques such as heater probe thermocoagulation, hemoclipping, argon plasma coagulation, and band ligation 4, 2, 5, 3.
- The use of proton pump inhibitors and antiemetics may also be recommended, although their efficacy is not well established in the literature 3.
Clinical Course and Outcomes
- Mallory-Weiss syndrome is often self-limiting, with bleeding ceasing spontaneously in most cases 6, 2.
- However, some patients may require therapeutic endoscopic intervention due to active bleeding, and the condition can have a poor outcome in certain cases, such as in cirrhotic patients 6, 5.
- Early gastroscopy and endoscopic treatment can guarantee effective control of the clinical course of Mallory-Weiss syndrome 5.