How is gastrointestinal bleeding in Mallory-Weiss syndrome typically managed?

Management of Gastrointestinal Bleeding in Mallory-Weiss Syndrome

Gastrointestinal bleeding in Mallory-Weiss syndrome stops spontaneously with nonoperative management in most cases (c). This condition, characterized by mucosal tears at the gastroesophageal junction, typically has a self-limiting course with excellent outcomes when managed conservatively.

Clinical Characteristics and Diagnosis

• Mallory-Weiss syndrome accounts for approximately 15% of upper gastrointestinal bleeding cases 1
• The condition is characterized by longitudinal mucosal tears at the gastroesophageal junction, not in the lower one-third of the esophagus 2, 3
• Diagnosis is best confirmed by upper gastrointestinal endoscopy, with a diagnostic accuracy of over 90% 4
• Common precipitating factors include:
  • Violent vomiting (most common)
  • Alcoholic debauch
  • Migraine
  • Abdominal trauma
  • Increased intraesophagogastric pressure 5, 6

Management Approach

First-Line Management

• Conservative management is the mainstay of treatment as bleeding stops spontaneously in approximately 75% of cases 1, 6
• Initial management includes:
  • Blood replacement therapy
  • Fluid resuscitation
  • Monitoring of vital signs 5
• Proton pump inhibitors and antiemetics are commonly used, though evidence for their efficacy is limited 3

Endoscopic Management

• Endoscopic intervention is only required for active bleeding or signs of recent bleeding that hasn't stopped spontaneously 2, 3
• Effective endoscopic techniques include:
  • Injection therapy with adrenaline (most commonly used at 13.7%) 7
  • Endoscopic clipping (12.8%) 7
  • Band ligation (appears to be most efficient for primary hemostasis) 3
  • Thermal methods (heater probe or multipolar coagulation) 2

Surgical Management

• Surgery is rarely required (only 0.1% of cases) 7
• Surgical intervention should only be considered in cases of:
  • Massive or persistent hemorrhage unresponsive to conservative and endoscopic management
  • Continued bleeding after transfusion of more than 1,500 ml of blood 4

Prognostic Factors

• Overall in-hospital mortality is approximately 2.7% 7
• Poor prognostic factors include:
  • Hypovolemic shock
  • Acute kidney injury
  • Sepsis
  • Need for artificial ventilation
  • Adult respiratory distress syndrome
  • Severe bleeding anemia
  • Female sex 7

Common Misconceptions

• Balloon tamponade (option b) is not typically used for Mallory-Weiss tears, as it's more appropriate for variceal bleeding
• Occult bleeding (option a) is not characteristic; bleeding is usually overt with hematemesis
• The tears occur at the gastroesophageal junction, not in the lower one-third of the esophagus (option d) 2, 3

Clinical Pearls

• Early endoscopy (within 24 hours) is recommended for diagnosis and potential intervention 1
• Once bleeding has stopped and oral intake is authorized, patients can be advanced to regular diet within 24 hours 2
• The need for surgical intervention has decreased significantly with improvements in endoscopic techniques 6
• Patients with Mallory-Weiss tears without active bleeding can be safely discharged early after stabilization 2