How do you differentiate and manage esophageal varices (enlarged veins) versus Mallory-Weiss tear (mucosal tear) in a patient with suspected upper gastrointestinal bleeding?

Differentiation and Management of Esophageal Varices versus Mallory-Weiss Tear in Upper GI Bleeding

Esophagogastroduodenoscopy (EGD) is the gold standard for differentiating between esophageal varices and Mallory-Weiss tears in suspected upper gastrointestinal bleeding, with distinct management protocols required for each condition based on their unique pathophysiology and bleeding risk. 1

Clinical Differentiation

History and Presentation

• Esophageal Varices:

  • Associated with cirrhosis and portal hypertension
  • Often presents with massive hematemesis
  • May have known liver disease, jaundice, ascites, encephalopathy
  • Risk factors: alcoholic liver disease, hepatitis, Child B/C cirrhosis 1

• Mallory-Weiss Tear:

  • Often preceded by forceful vomiting or retching
  • Usually self-limited bleeding
  • No underlying liver disease required
  • May have history of alcohol intake, bulimia, or severe coughing 2

Physical Examination

• Esophageal Varices:

  • Signs of chronic liver disease (spider angiomas, palmar erythema)
  • Splenomegaly, ascites, jaundice
  • May have encephalopathy

• Mallory-Weiss Tear:

  • Generally normal examination except for signs of blood loss
  • Absence of stigmata of chronic liver disease

Endoscopic Findings

Esophageal Varices

• Dilated, tortuous submucosal veins in the distal esophagus
• Classified by size: small (<5mm) or large (>5mm)
• May have "red wale marks" (high bleeding risk)
• Cross the gastroesophageal junction in many cases 1

Mallory-Weiss Tear

• Linear mucosal laceration at the gastroesophageal junction
• Usually on the gastric side of the junction
• May show active bleeding, visible vessel, or clean base
• Typically 1-4 cm in length 2, 3

Management Approach

Initial Resuscitation (Both Conditions)

1. Hemodynamic stabilization:

   • Restrictive transfusion strategy (target hemoglobin 7-9 g/dL)
   • Avoid excessive fluid resuscitation which can increase portal pressure 4

2. Airway protection if altered mental status or massive bleeding 4

Management of Esophageal Varices

1. Immediate pharmacological therapy:

   • Start vasoactive drugs (terlipressin, somatostatin, or octreotide) immediately upon suspicion
   • Continue for 3-5 days after bleeding control 4

2. Prophylactic antibiotics:

   • Start immediately (ceftriaxone or norfloxacin)
   • Continue for up to 7 days 4

3. Endoscopic therapy:

   • Perform within 12 hours of admission
   • Endoscopic variceal ligation (EVL) is first-line therapy
   • Band ligation of varices until eradication 1, 4

4. Management of persistent bleeding:

   • Transjugular intrahepatic portosystemic shunt (TIPS) for rescue therapy
   • Balloon tamponade or self-expanding esophageal stents as temporary bridge 4

5. Prevention of rebleeding:

   • Combination of NSBBs and EVL
   • Follow-up endoscopies until variceal eradication 1

Management of Mallory-Weiss Tear

1. Observation for non-actively bleeding tears:

   • Most tears (80-85%) stop bleeding spontaneously
   • No specific treatment needed if no active bleeding or visible vessel 2, 3

2. Endoscopic therapy for active bleeding or visible vessel:

   • Multipolar electric coagulation (MPEC) is well-supported by evidence
   • Endoscopic hemoclipping is emerging as first-line therapy
   • Epinephrine injection is effective (avoid in coronary artery disease)
   • Band ligation can also be effective 2, 5

3. Post-procedure care:

   • Brief observation period for uncomplicated cases
   • Discharge possible after 24 hours if no rebleeding 3

Important Distinctions and Pitfalls

1. Coexisting conditions:

   • Up to 26% of patients with known esophageal varices may bleed from another source, including Mallory-Weiss tears 6
   • Complete endoscopic examination of the upper GI tract is essential

2. Risk assessment:

   • Mallory-Weiss tears: Higher risk of significant bleeding with coagulopathies or portal hypertension 3
   • Esophageal varices: Higher risk with Child B/C cirrhosis, large varices, and red wale marks 1

3. Treatment contraindications:

   • Avoid MPEC when esophageal varices are suspected as it may worsen bleeding
   • Use band ligation or polidocanol injection instead 2

4. Mortality considerations:

   • Despite lower rebleeding rates with Mallory-Weiss tears (4.9% vs 12% for peptic ulcers), mortality remains significant (5.7%) 5
   • Variceal bleeding has 20% mortality at 6 weeks despite treatment advances 1

By systematically evaluating clinical presentation and endoscopic findings, clinicians can accurately differentiate between these conditions and implement appropriate management strategies to reduce morbidity and mortality.