From the Guidelines
Patients with a Mallory-Weiss tear can be fed and discharged home immediately after stabilization if they are at low risk for rebleeding, as determined by endoscopic findings and clinical status. This approach is supported by a randomized trial that showed the time of refeeding does not influence the hospital course of patients at low risk 1. Management of a Mallory-Weiss tear primarily involves supportive care, including stopping any bleeding, addressing the underlying cause, and preventing complications. For active bleeding, endoscopic treatment is the first-line approach, which may include injection of epinephrine, application of hemoclips, or thermal coagulation.
Key Considerations
- Patients with major hemorrhage and endoscopic findings of a Mallory-Weiss tear or an ulcer with a clean base, flat spot, or clot may be fed and discharged home immediately after stabilization, as per the consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding 1.
- The decision to feed and discharge patients is made on a case-by-case basis, depending on the patient's clinical status and the likelihood of repeated endoscopy or surgery.
- Patients with upper GI bleeding should be tested for Helicobacter pylori and receive eradication therapy if infection is present, as eradication of H. pylori has been demonstrated to reduce the rate of ulcer recurrence and rebleeding in complicated ulcer disease 1.
Treatment Options
- Endoscopic treatment for active bleeding, including injection of epinephrine, application of hemoclips, or thermal coagulation.
- Medications such as proton pump inhibitors like omeprazole or pantoprazole to reduce stomach acid and promote healing.
- Antiemetics such as ondansetron to control nausea and vomiting.
- Patients should avoid alcohol, NSAIDs, and activities that increase abdominal pressure.
Severe Cases
- Severe cases with significant bleeding may require blood transfusions or, rarely, angiographic embolization or surgery.
From the Research
Definition and Causes of Mallory-Weiss Tear
- A Mallory-Weiss tear is a mucosal laceration occurring at or near the esophagogastric junction, often associated with vomiting 2.
- It is a common cause of upper gastrointestinal bleeding, accounting for 14% of patients presenting to the hospital with upper gastrointestinal bleeding 2.
- The tear can be caused by various factors, including non-bloody emesis followed by hematemesis, and can be associated with other potential bleeding sites 2.
Clinical Features and Management
- Patients with Mallory-Weiss tear may present with upper gastrointestinal bleeding, and nearly half of them may have no antecedent symptoms such as nausea, retching, abdominal pain, or vomiting 3.
- Endoscopic therapy is a very effective and safe method for producing hemostasis in patients with Mallory-Weiss tear, with a success rate of 100% in some studies 3.
- The management of Mallory-Weiss tear depends on the type and location of the lesion, the patient's comorbid conditions, and the availability of different therapeutic modalities 4.
- Endoscopic injection therapy, argon plasma coagulation, hemoclip placement, and band ligation are commonly used endoscopic treatments for actively bleeding Mallory-Weiss tear 5.
Treatment Options
- Endoscopic injection therapy using epinephrine and polidocanol is a useful option in the management of patients with Mallory-Weiss syndrome at high risk for recurrent bleeding 6.
- Multipolar electric coagulation (MPEC) is a treatment modality with better evidence-based support for safety and bleeding control, but it should be avoided in patients with suspected esophageal varices 4.
- Endoscopic band ligation and polidocanol injection are emerging as safe and effective treatment modalities, even in patients without varices 4.
- Surgical treatment may be necessary if bleeding continues or recurs despite endoscopic therapy, but radiologic hemostasis with selective vasopressin or Gelfoam embolization is a viable alternative in some cases 4.