From the Guidelines
An Esophagogastroduodenoscopy (EGD) is recommended for a Mallory-Weiss tear, especially in cases of severe haemorrhage, as it allows for both diagnosis and potential endoscopic therapy to arrest bleeding. The procedure is crucial for directly visualizing the tear, assessing its severity, and determining if active bleeding is present 1. According to the guidelines for non-variceal upper gastrointestinal haemorrhage, endoscopic therapy is indicated for treating ulcers with major stigmata of recent haemorrhage, and while Mallory-Weiss tears often stop bleeding spontaneously, occasional endoscopic therapy is needed to arrest severe haemorrhage 1.
Key Points for Consideration:
- EGD serves as both a diagnostic and therapeutic tool for Mallory-Weiss tears.
- The procedure allows for the direct visualization of the tear and assessment of its severity.
- Endoscopic therapy, including injection using adrenaline or thermal methods, is almost always effective for Mallory-Weiss tears with severe haemorrhage 1.
- Patients undergoing EGD for a Mallory-Weiss tear should be prepared for potential therapeutic interventions during the procedure.
Procedure and Preparation:
The EGD procedure for a Mallory-Weiss tear is typically performed under conscious sedation. Patients should fast for at least 6 hours before the procedure and arrange for someone to drive them home afterward due to sedation effects. The choice of sedation medications, such as midazolam and fentanyl, should be based on the patient's medical history and current health status.
Evidence Support:
The recommendation for EGD in Mallory-Weiss tears is supported by guidelines that emphasize the importance of endoscopic evaluation and therapy in managing non-variceal upper gastrointestinal haemorrhage 1. While the specific study cited is from 2002, its principles regarding the management of Mallory-Weiss tears and the role of EGD remain relevant, highlighting the need for a tailored approach based on the severity of the tear and the presence of active bleeding.
From the Research
Diagnosis and Treatment of Mallory-Weiss Tear
- An Esophagogastroduodenoscopy (EGD) is recommended for diagnosing a Mallory-Weiss tear, as it allows for the visualization of the tear and the assessment of active bleeding or stigmata of recent bleeding 2, 3, 4, 5.
- The treatment modality chosen depends on the type and location of the lesion, the patient's comorbid conditions, the availability of the different therapeutic modalities, and the experience of the endoscopist with each of these different modalities 2.
- If the Mallory-Weiss tear is not actively bleeding at the time of endoscopy, no further treatment is needed owing to a low risk of rebleeding, unless a visible vessel is present 2.
- Endoscopic treatment modalities, such as multipolar electric coagulation, polidocanol injection, endoscopic band ligation, epinephrine injection, and endoscopic hemoclipping, may be used to control bleeding in patients with active bleeding or stigmata of recent bleeding 2, 3, 4, 5.
Indications for EGD
- Patients with symptoms of upper gastrointestinal bleeding, such as hematemesis, should undergo an EGD to diagnose and treat a Mallory-Weiss tear 3, 5.
- Patients with active bleeding or signs of recent bleeding at endoscopy need immediate endoscopic treatment for hemostasis 5.
- Patients without risk factors for rebleeding, clinical features indicating severe bleeding, or active bleeding at endoscopy can be managed with a brief period of observation 3.
Treatment Options
- Endoscopic band ligation seems to be the most efficient procedure for primary hemostasis and for preventing recurrent bleeding 5.
- Other endoscopic treatment modalities, such as multipolar electric coagulation, polidocanol injection, epinephrine injection, and endoscopic hemoclipping, may also be used to control bleeding in patients with active bleeding or stigmata of recent bleeding 2, 3, 4.
- Radiologic hemostasis with selective vasopressin or Gelfoam embolization may be used as a viable treatment alternative in patients who are not candidates for surgical treatment 2, 6.