What is the best management approach for Mallory-Weiss syndrome?

Management of Mallory-Weiss Syndrome

The best management approach for Mallory-Weiss syndrome is primarily conservative care, as most tears stop bleeding spontaneously, with endoscopic intervention reserved for active bleeding cases. 1, 2

Clinical Assessment and Risk Stratification

• Mallory-Weiss tears are mucosal lacerations typically located posteriorly across the gastroesophageal junction, often associated with forceful retching or vomiting 2
• In the Rockall scoring system for upper GI bleeding risk assessment, Mallory-Weiss tears are categorized as low-risk lesions with an excellent prognosis 1
• Patients with normal vital signs (no tachycardia or hypotension), hemoglobin >100 g/L, and minimal comorbidities can be managed conservatively 1
• Assess for shock (pulse >100 beats/min and systolic BP <100 mmHg), which indicates higher risk and need for more aggressive management 1

Initial Management

• For hemodynamically stable patients with mild bleeding:

  • Admit to a general medical ward with hourly vital sign monitoring 1
  • Allow oral fluids if the patient is stable 1
  • Measure urine output to assess volume status 1
  • Schedule endoscopy on the next available list to confirm diagnosis 1

• For severe bleeding with hemodynamic instability:

  • Establish intravenous access for fluid resuscitation 1
  • Maintain hemoglobin >7 g/dL (4.5 mmol/L) during resuscitation 1
  • Target mean arterial pressure >65 mmHg while avoiding fluid overload 1
  • Correct any coagulopathy 1
  • Arrange urgent endoscopy 1

Endoscopic Management

• For active bleeding or visible vessels, endoscopic intervention is indicated 3, 4

• Effective endoscopic treatment options include:

  • Hemoclip placement (mean 2.5 clips per procedure) 3, 5
  • Epinephrine injection (mean volume 7.9 mL) 3, 6
  • Band ligation (mean 1.2 bands per procedure) 5, 7
  • Argon plasma coagulation 4

• Recent evidence suggests band ligation may be the most efficient procedure for primary hemostasis and preventing recurrent bleeding 7

• Both hemoclip placement and endoscopic band ligation have shown equal efficacy and safety, even in patients with shock or comorbid diseases 5

Post-Endoscopic Care

• After successful endoscopy with no stigmata of recent hemorrhage:

  • Early discharge from hospital is appropriate 1
  • Once oral food is authorized, start with liquids and advance to standard hospital diet within 24 hours 1
  • Patients with clean-based ulcers or non-bleeding Mallory-Weiss tears may be refed early with regular hospital diet and discharged immediately after stabilization 1

• For patients with successful endoscopic treatment:

  • Monitor for recurrent bleeding, which occurs in approximately 5-10% of cases 3, 5
  • Secondary hemostasis can typically be achieved by repeating the same endoscopic procedure if rebleeding occurs 3, 5

Pharmacological Therapy

• Proton pump inhibitors and antiemetics are commonly used, though evidence specifically for Mallory-Weiss syndrome is limited 7
• Address underlying causes of vomiting to prevent recurrence 1

Special Considerations

• In patients with cyclic vomiting syndrome who develop Mallory-Weiss tears, recognize these as epiphenomena of recent retching and vomiting rather than primary causes of symptoms 1
• Avoid repeated endoscopies unless clinically indicated by recurrent bleeding 1

Prognosis

• Most Mallory-Weiss tears have an excellent prognosis with appropriate management 1, 2
• Surgery is rarely required with modern endoscopic techniques 3, 6, 5
• Mortality is almost exclusively restricted to patients with significant comorbidities 1