What is the management of a Mallory-Weiss tear?

Management of Mallory-Weiss Tear

Initial Assessment and Risk Stratification

Most Mallory-Weiss tears stop bleeding spontaneously and require only supportive care, but patients with active bleeding or hemodynamic instability need urgent endoscopic intervention. 1, 2

Identify High-Risk Features

• Hemodynamic instability: Pulse >100 beats/min AND systolic BP <100 mmHg indicates shock and higher mortality risk 1, 2
• Active bleeding at endoscopy: Associated with higher transfusion requirements and need for intervention 3
• Coagulopathy or portal hypertension: Significantly increases rebleeding risk and transfusion needs 3
• Hematochezia as presenting symptom: Indicates more severe bleeding 3
• Age and comorbidities: Mortality almost exclusively occurs in patients with significant comorbid diseases (cardiac, renal, hepatic, malignancy) 1, 2

Rockall Score Application

• Mallory-Weiss tears are categorized as low-risk lesions with excellent prognosis in the Rockall scoring system 1, 2
• Patients with Rockall score <3 have excellent prognosis; score >8 indicates high mortality risk 1

Resuscitation and Initial Management

Hemodynamically Stable Patients

• Admit to general medical ward with hourly vital sign monitoring 2
• Establish IV access for potential fluid resuscitation 2
• No endoscopic therapy needed if tear is not actively bleeding at endoscopy 1, 4
• Early feeding within 24 hours and discharge after successful endoscopy showing no stigmata of recent hemorrhage 1, 2

Hemodynamically Unstable or Actively Bleeding Patients

• Place two large-bore IV catheters immediately 2
• Aggressive volume resuscitation with normal saline targeting mean arterial pressure >65 mmHg 2
• Transfuse blood when hemoglobin <100 g/L or bleeding is severe 2
• Urgent endoscopy after stabilization to identify and treat bleeding source 1

Endoscopic Management

Indications for Endoscopic Therapy

Endoscopic intervention is indicated for: 1, 4, 3

• Active arterial bleeding at time of endoscopy
• Visible vessel present (even without active bleeding)
• Severe hemorrhage requiring urgent hemostasis

Endoscopic Treatment Options

All of the following modalities are effective; choice depends on endoscopist experience and clinical scenario: 1, 4, 5

First-Line Options:

1. Epinephrine injection (1:10,000 solution): Inject 4-16 ml in quadrants around bleeding point, achieves hemostasis in up to 95% 1

   • Avoid in patients with coronary artery disease due to systemic absorption risk 5

2. Thermal methods (heater probe or multipolar coagulation): Apply at 20-30 joules repeatedly until hemostasis achieved 1

   • Avoid when esophageal varices suspected as it may precipitate bleeding 5
   • Multipolar electric coagulation has best evidence-based support for safety and bleeding control 5

3. Argon plasma coagulation: Effective alternative thermal method 1, 4

4. Hemoclips: Particularly useful for actively bleeding large vessels 4, 5

   • Emerging as first-line modality but not universally available 5

5. Band ligation: Safe and effective, especially useful when varices are suspected 4, 5

Combination Therapy:

• For active arterial bleeding: Combination of epinephrine injection plus heater probe superior to injection alone 1

Post-Endoscopic Management

Immediate Post-Procedure Care

• Monitor vital signs closely for 4-6 hours after endoscopy 2
• Begin oral liquids and advance to regular diet within 24 hours once hemodynamically stable 1, 2
• Address underlying causes of vomiting to prevent recurrence 2

Pharmacologic Therapy

• Proton pump inhibitors recommended after endoscopic therapy, though optimal dosing for Mallory-Weiss tears specifically is not well-established 1
• Standard dosing: Omeprazole 40 mg orally every 12 hours for 5 days 1

Rebleeding Management

Risk Factors for Rebleeding

• Coagulopathy or bleeding diathesis 3
• Portal hypertension 3
• Rebleeding is unusual and typically occurs within 24 hours 3

If Rebleeding Occurs

• Repeat endoscopic therapy as first-line approach 5
• Surgical intervention if bleeding continues or recurs despite endoscopic therapy 5
• Radiologic hemostasis (selective vasopressin or Gelfoam embolization) for non-surgical candidates 5

Discharge Criteria

Patients can be discharged early if: 1, 2, 3

• No active bleeding at endoscopy
• Hemodynamically stable
• No coagulopathy or portal hypertension
• No stigmata of recent hemorrhage
• Clean-based tear or flat spot only

Avoid hospitalization in low-risk patients without risk factors for rebleeding, clinical features of severe bleeding, or active bleeding at endoscopy 3