What is the appropriate initial management for a Mallory‑Weiss tear?

Management of Mallory-Weiss Tears

Initial Assessment and Risk Stratification

Most Mallory-Weiss tears stop bleeding spontaneously and require only conservative management with hemodynamic support, as they are categorized as low-risk lesions with excellent prognosis in the Rockall scoring system. 1, 2

Key Prognostic Factors to Assess

• Age: Mortality is rare in patients under 40 years but increases to 30% in those over 90 years 1
• Hemodynamic status: Check for shock (pulse >100 bpm AND systolic BP <100 mmHg), which significantly increases risk 1, 2
• Comorbidities: Deaths are almost entirely restricted to patients with cardiac failure, ischemic heart disease, renal failure, liver failure, or disseminated malignancy 1, 3
• Endoscopic findings: Mallory-Weiss tears with clean base or no active bleeding carry very low risk of rebleeding and death 1

Conservative Management (First-Line for Most Patients)

For hemodynamically stable patients without active bleeding, conservative management is appropriate. 1, 2

• Establish IV access for fluid resuscitation 2
• Admit to general medical ward with hourly vital sign monitoring 2
• Target mean arterial pressure above 65 mmHg while avoiding fluid overload 2
• Address underlying causes of vomiting to prevent recurrence 2
• Start liquids and advance to standard diet within 24 hours once oral intake is authorized 2
• Early discharge is appropriate after successful endoscopy showing no stigmata of recent hemorrhage 2

Endoscopic Intervention (For Active or Severe Bleeding)

Endoscopic therapy is needed only occasionally to arrest severe hemorrhage, but when required, adrenaline injection or thermal methods are almost always effective. 1

Endoscopic Treatment Options

• Injection therapy: Use 1:10,000 adrenaline solution in quadrants around bleeding point, achieving primary hemostasis in up to 95% of cases 1, 4, 5
• Thermal methods: Heater probe (20-30 joules) or argon plasma coagulation are as effective as adrenaline injection 1, 4
• Mechanical clips: Hemoclip placement is particularly useful for actively bleeding large vessels 1, 4
• Band ligation: Effective alternative treatment that is inexpensive and readily available, with excellent hemostasis rates 6, 4, 7

When to Perform Endoscopic Therapy

Endoscopic intervention is indicated for patients with:

• Active bleeding visualized at endoscopy 4, 7
• Stigmata of recent bleeding (visible vessel, adherent clot) 7
• Hemodynamic instability despite resuscitation 5

Common Pitfalls to Avoid

• Do not assume all patients need endoscopic therapy: 75% of Mallory-Weiss tears stop bleeding spontaneously 1, 7
• Do not delay endoscopy in shocked patients: Those with pulse >100 and BP <100 require urgent assessment 1
• Do not overlook comorbidities: These are the primary determinants of mortality, not the tear itself 1, 3
• Do not use H2 receptor antagonists: There are no convincing data supporting their use, as they do not reliably increase gastric pH to 6 1

Pharmacological Considerations

While proton pump inhibitors have shown benefit in peptic ulcer bleeding, their specific role in Mallory-Weiss tears is less established, though their use seems logical to optimize clot stability 1, 7. Antiemetics should be used to prevent recurrent vomiting and further tearing 7.