What is the immediate management for a patient with suspected or confirmed Mallory-Weiss syndrome presenting with hypotension, vertigo, headache, and hematemesis?

Immediate Management of Mallory-Weiss Syndrome with Hypotension

For a patient with suspected or confirmed Mallory-Weiss syndrome presenting with hypotension, vertigo, headache, and hematemesis, immediate fluid resuscitation with balanced crystalloids targeting a systolic blood pressure of 80-90 mmHg until bleeding is controlled is the first priority, followed by urgent endoscopy once the patient is hemodynamically stable.

Initial Resuscitation and Stabilization

Hemodynamic Management

• Establish two large-bore IV lines (18G or larger)
• Begin fluid resuscitation with balanced crystalloids at 10-20 mL/kg 1
• Target systolic blood pressure 80-90 mmHg initially until bleeding is controlled 1
• Once bleeding is controlled, aim for MAP ≥65 mmHg 2
• Position patient in supine position to improve cerebral perfusion 2
• Avoid excessive fluid administration which may increase hydrostatic pressure on bleeding sites and dislodge clots 1

Blood Product Administration

• Implement restrictive transfusion strategy to maintain hemoglobin >7 g/dL 2, 1
• Consider transfusion thresholds for management of active bleeding: hematocrit >25%, platelet count >50,000, and fibrinogen >120 mg/dL 2
• Correct coagulopathy if present 2

Vasopressor Support (if needed)

• Use norepinephrine (0.05-2 mcg/kg/min) as first-line vasopressor if fluid resuscitation fails to restore blood pressure 1
• Avoid vasopressors that may worsen splanchnic vasoconstriction if possible 2

Diagnostic Approach

Immediate Measures

• Obtain baseline laboratory tests: CBC, comprehensive metabolic panel, coagulation studies, type and cross 2
• Apply the Rockall scoring system to assess risk (Mallory-Weiss tear is considered low risk with score 0 in diagnosis category) 2
• Prepare for urgent endoscopy once patient is hemodynamically stable 2

Endoscopic Management

• Perform urgent upper endoscopy within 24 hours of presentation, ideally after initial resuscitation 2, 3
• Look for longitudinal mucosal tear at the esophagogastric junction, which confirms Mallory-Weiss syndrome 3
• If active bleeding is present, perform endoscopic hemostasis:
  • Band ligation appears to be the most efficient procedure for primary hemostasis 3
  • Alternative options include hemoclipping, local injection therapy, or multipolar electrocoagulation 4

Pharmacological Management

Acid Suppression

• Administer high-dose IV proton pump inhibitor (e.g., pantoprazole 80mg IV bolus followed by 8mg/hr infusion) 2
• Continue PPI therapy until endoscopy confirms hemostasis 2

Antiemetics

• Administer antiemetics to prevent further vomiting which could worsen the tear 3
• Consider ondansetron 4-8mg IV or prochlorperazine 5-10mg IV

Bridging Measures (if bleeding is severe and endoscopy delayed)

• Consider endorectal placement of a compression tube (e.g., Sengstaken-Blakemore) as a temporary bridging measure 2, 5
• This can help stabilize the patient or facilitate transfer to a tertiary hospital if needed 2

Monitoring and Ongoing Assessment

• Continuous vital sign monitoring including heart rate, blood pressure, respiratory rate, and oxygen saturation
• Serial hemoglobin/hematocrit measurements every 4-6 hours until stable
• Monitor for signs of rebleeding: recurrent hematemesis, melena, or hemodynamic instability
• Assess for vertigo and headache improvement as blood pressure normalizes

Risk Factors for Poor Outcomes

Be particularly vigilant in patients with:

• Advanced age 6
• Very low hemoglobin level 6
• Elevated AST level (suggesting liver dysfunction) 6
• Presence of tarry stool (indicating significant bleeding) 6
• Comorbid liver cirrhosis, which significantly worsens prognosis 5

Common Pitfalls to Avoid

• Delaying endoscopy in unstable patients - stabilize first, then perform endoscopy
• Excessive fluid resuscitation which may worsen bleeding by increasing portal pressure 2
• Normalizing blood pressure too quickly, which may dislodge forming clots 1
• Failing to consider other sources of upper GI bleeding - up to 8% of patients with diverticulosis and hematochezia may have an upper source 2
• Overlooking the need for antiemetics to prevent further vomiting and potential worsening of the tear

Mallory-Weiss syndrome typically has a benign course with spontaneous cessation of bleeding in most cases 3, but patients presenting with hypotension require immediate attention to prevent complications and reduce mortality.