mallory weiss tear

1. Mallory Weiss Tear Ruth O�Carroll R4 July 7, 2006

3. Intro upper GI bleeding 2? to longitudinal mucosal lacerations/tears near or at GE junction or gastric cardia ? transmural original description by Kenneth Mallory and Soma Weiss in 1929 involved patients with persistent retching and vomiting following an alcoholic binge Can extend up the distal esophagusCan extend up the distal esophagus

5. Pathophysiology rapid rise in intragastric pressure ppting factors retching vomiting ? transmural pressure gradient across hiatal hernia negative intrathoracic pressure and positive intragastric pressure leads to distortion of gastric cardia resulting in gastric or esophageal tear shearing forces are > enough longitudinal laceration eventually occurs 120-160mmHg tear is more likely to involve lesser curvature of gastric cardia relatively immobile violent prolapse/intussusception of stomach into esophagus forceful retching at endoscopy large, rapidly occurring, and transient transmural pressure gradient across the region of GE junction Acute distension of nondistensible lower esophagus can also produce a linear tear in this region. In cadavers intragastric pressure >15ommHg produced mucosal lacerations large, rapidly occurring, and transient transmural pressure gradient across the region of GE junction Acute distension of nondistensible lower esophagus can also produce a linear tear in this region. In cadavers intragastric pressure >15ommHg produced mucosal lacerations

6. Stats 1-15% UGI bleeds in the US ? racial predilection ?:? 2-4:1 Age - 40s/50s age range is quite wide

7. Presentation Episode of hematemesis following a bout of retching or vomiting Hematemesis is present in 85% of pts Less common presenting syx Melena Hematochezia Syncope Abdominal pain Excessive EtOH use reported in 40-75% Aspirin use in up to 30% Attempt to identify a precipitating factor for the MWT although this presentation may be less common than previously thought. Graham and Schwartz found that a typical history was obtained in only about 30% of patients. In a study by Harris and DiPalma, hematemesis on first emesis was reported in 50% of patients. although this presentation may be less common than previously thought. Graham and Schwartz found that a typical history was obtained in only about 30% of patients. In a study by Harris and DiPalma, hematemesis on first emesis was reported in 50% of patients.

8. Ppting factors Presence of hiatal hernia 35-100% Retching Vomiting Straining Hiccuping Transesophageal echo Esophageal dilatation Coughing Primal scream therapy Blunt abdominal trauma Child birth Bowel prep with PEG lavage CPR EtOH use >90% pt Cirrhosis/portal HTN ? M&M

9. Physical exam findings relate to rate + degree of blood loss Tachycardia Hypotension Orthostatic changes Overt shock

10. Initial Management ABCs then 2 large bore IVs Monitor U/O Blood work Gastric lavage/NG tube

11. Lab Studies CBC Lytes Coags Group/screen +/-crossmatch ECG +/- cardiac enzymes

12. Management Early endoscopy Within 24h

13. Endoscopy ID active bleeding, adherent clot, or fibrin crust over mucosal split within/near GE jxn split ~ 2-3cm in length few mm in width >80% pts present with single tear usual location of the tear (50-80% pt) just below GE jxn on lesser curve of stomach b/w 2 + 6 o'clock on endoscopic viewing with pt in left lateral decubitus position 9-18% extend to esophagus

14. Endoscopy cont. Important to ID other cause 80% pt have coexisting lesion Gastric, DU Esophagitis Varices Duodenitis

15. To treat, or not to treat? actively bleeding MWTs are treated arterial spurting streaming from focal point diffuse oozing nonbleeding visible vessel or adherent clot ? necessarily require tx Treat if rebleeding episodes from same lesion associated with a coagulopathy clean, fibrinous base or with flat, pigmented spots ? treated risk of rebleeding is minimal

16. Endoscopic tx Choice depends on endoscopist's familiarity with particular technique + equipment availability Heater probe Epinephrine (1:10,000-1:20,000) Sclerosants - ? advised Argon Plasma coagulator Endoscopic band ligation/hemoclipping ? use balloon tamponade Selective vasopressin infusion/embolization of left gastric artery

17. Higuchi et al 2006 prospective study August �98 - June �05 37 pts with MWT who had active bleeding, exposed vessels, or both treated using endoscopic band ligation successful in 36/37 cases f/u 1-24 mo ? recurrent bleeding, perforation, or other complications 1 mortality - severe liver failure + DIC

18. Park et al 2004 Prospective trial 34 consecutive pts actively bleeding MWT randomly assigned to undergo endoscopic band ligation or endoscopic injections of a 1:10,000 solution of epinephrine # of elastic bands applied was 1-2 mean volume of epinephrine injected was 18.0 mL Primary hemostasis band ligation group 17/17 epinephrine injection group 16/17 ? recurrence of bleeding or major complication in either group ? significant difference between the groups with respect to age, gender, alcohol ingestion, presenting symptoms, Hb level, shock, comorbid diseases, coagulopathy, tear location, blood transfusion, or duration of hospitalization.? significant difference between the groups with respect to age, gender, alcohol ingestion, presenting symptoms, Hb level, shock, comorbid diseases, coagulopathy, tear location, blood transfusion, or duration of hospitalization.

19. Course Most have stopped bleeding at time of endoscopy 80-90% heal uneventfully within 48h 5-35% require some form of intervention mostly endoscopic Supportive care volume +/- blood replacement acid suppression antiemetic drug therapy Surgical Care oversewing of tear is reserved for MWT refractory to endoscopic therapy or angiotherapy

20. Kim et al 2005 Retropsective review Jan�99 � Dec�03 159 pt 22 ?, 137 ? mean age 48.1yo Recurrent bleeding in 17 patients (10.7%) ? frequency for the presence of shock at initial manifestation (OR 3.71, 95% CI 1.07-14.90) combined liver cirrhosis endoscopic findings of active bleeding (OR 9.89, 95% CI 1.88-51.98) ? Hb and platelet count ? transfusions ? epinephrine-mixed fluid injections longer hospital stay

21. Vasopressin Some benefit in pt with continued bleeding Continuous infusion over 48h Bolus 20U then 0.4-0.6U/min No prospective studies

22. Surgery 3-9% cases Continued bleeding despite endoscopy + correction of coags Threshhold 6U RBC Method ? No prospective dataNo prospective data

23. Sx tx Upper midline incision Longitudinal ant. gastrotomy Examine gastric mucosa +/- mobilize GE jxn Try 2 NG tubes Large foley+/-sigmoidoscope Oversew with absorbable suture Distal?proximal

24. Summary Dx from history Early endoscopy Most heal without intervention Numerous endoscopic modalities to control bleeding If continued bleeding/shocky ? OR

25. References Cameron, Current Surgical Therapy. Higuchi, N., et al. (2006) Endoscopic band ligation therapy for upper gastrointestinal bleeding related to Mallory-Weiss syndrome. Surg Endosc. May 15. Kim, J., et al. (2005) Predictive factors of recurrent bleeding in Mallory-Weiss syndrome. Korean J Gastroenterol. 46(6):447-54. Park, C., et al. (2004) A prospective, randomized trial of endoscopic band ligation vs. epinephrine injection for actively bleeding Mallory-Weiss syndrome. Gastrointest Endosc. 60(1):22-7. www.emedicine.com