Management of Mallory-Weiss Syndrome and Esophageal Varices
Mallory-Weiss Syndrome
Most Mallory-Weiss tears stop bleeding spontaneously and require only medical observation, with endoscopic intervention reserved exclusively for active bleeding (spurting or oozing). 1
Initial Assessment and Conservative Management
Medical observation alone is appropriate for patients without active bleeding stigmata (protruding visible vessels or adherent clots only), as these patients have essentially zero rebleeding risk regardless of intervention. 1
Conservative management successfully controls bleeding in the majority of cases without requiring endoscopic therapy. 2
Endoscopic Intervention for Active Bleeding
When active bleeding (spurting or oozing) is present at endoscopy, mechanical hemostatic methods are superior to injection therapy:
Endoscopic hemoclip placement or band ligation achieves 100% hemostasis with zero rebleeding in patients with active bleeding stigmata. 1
Epinephrine injection (with or without hypertonic saline) is equally effective as hemoclipping for initial hemostasis but carries a higher rebleeding rate (29% vs 0%). 3, 1
Both hemoclip placement and epinephrine injection are safe even in patients with shock or significant comorbidities, with no procedure-related complications reported. 3
Critical Pitfall in Patients with Known Varices
In patients with previously documented esophageal varices presenting with recurrent upper GI bleeding, 26% will be bleeding from an alternative source (gastroduodenal ulcers, aphthous lesions, Mallory-Weiss tears, or hemorrhagic gastropathy) rather than varices. 4
Emergency endoscopy must visualize the entire upper GI tract, not just the esophagus, to avoid therapeutic errors—blind balloon tamponade based on variceal history will harm one-quarter of these patients. 4
Esophageal Varices
Immediate vasoactive drug therapy must be initiated as soon as variceal bleeding is suspected—before endoscopy—combined with prophylactic antibiotics and restrictive transfusion targeting hemoglobin 7-9 g/dL. 5, 6
Immediate Resuscitation (Within Minutes)
Establish large-bore IV access and implement restrictive transfusion strategy targeting hemoglobin 7-9 g/dL, as aggressive transfusion increases portal pressure and worsens outcomes. 5, 7
Start vasoactive drugs immediately upon suspicion (octreotide 50 µg IV bolus then 50 µg/hour infusion, or terlipressin 2 mg IV every 4 hours), continuing for 3-5 days after diagnosis confirmation. 8, 5, 6
Initiate antibiotic prophylaxis with ceftriaxone 1 g IV every 24 hours, which reduces infections, improves bleeding control, and decreases mortality. 5, 6, 7
Transfer to intensive care or monitored setting given high mortality risk. 5
Avoid beta-blockers during acute bleeding as they decrease blood pressure and blunt compensatory tachycardia. 5
Urgent Endoscopic Management (Within 12 Hours)
Perform endoscopy within 12 hours once hemodynamically stabilized for diagnosis and therapeutic intervention. 5, 6, 7
Endoscopic variceal ligation (EVL) is first-line endoscopic treatment, achieving hemostasis in approximately 90% of cases. 8, 5, 6
The combination of EVL plus vasoactive drugs is superior to either therapy alone, reducing very early rebleeding and treatment failure. 8
Rescue Therapies for Refractory Bleeding (10-20% of Cases)
Balloon tamponade serves as temporary bridge therapy for up to 24 hours maximum while arranging definitive treatment in uncontrolled bleeding. 5, 6, 7
Early TIPS placement is recommended for high-risk patients (HVPG ≥20 mmHg, Child-Pugh class C, or failure of combined pharmacologic-endoscopic therapy). 8, 5, 6
TIPS achieves 90-100% hemostasis in rescue settings but carries 15-25% risk of hepatic encephalopathy. 8, 7
Secondary Prevention Before Discharge
Start non-selective beta-blocker once recovered from acute bleeding and combine with repeat EVL sessions every 2-8 weeks until variceal eradication. 5
This combination reduces rebleeding to 14-23% versus 38-47% with EVL alone. 5
Gastric Varices (Special Considerations)
Gastric varices require different management based on anatomic location, with cyanoacrylate injection being superior to band ligation for fundal varices. 8, 6, 7
Initial Management
Initial resuscitation, vasoactive drugs, and antibiotics follow the same protocol as esophageal varices. 7
Obtain contrast-enhanced CT or MRI to identify inflow/outflow patterns, which determines feasibility of balloon-occluded retrograde transvenous obliteration (BRTO) and identifies portal/splenic vein thrombosis affecting treatment selection. 8, 7
Endoscopic Treatment by Varix Type
GOV1 varices (extension along lesser curvature) are managed identically to esophageal varices with EVL as first-line therapy. 8, 6
For fundal varices (GOV2, IGV1), cyanoacrylate injection is superior to band ligation, achieving 94% vs 80% control of active bleeding and significantly lower rebleeding rates (23% vs 47%). 8, 6, 7
Endoscopic sclerotherapy is less effective for gastric varices (67% hemostasis rate) and has been largely abandoned. 8