Medical Wizardry

Mallory Weiss Syndrome

We all would have experienced vomiting or throwing up at least once in our lifetime. It is just a forceful expulsion of stomach contents. Most of the time these are mild and resolve eventually. But when vomiting gets severe and prolonged on some occasions, it may result in damage to the esophagus producing dreadful complications. The esophagus is the tube that connects the throat to the stomach facilitating food transfer.

Mallory Weiss syndrome is a condition in which there is a tear in the esophagus. Specifically, it is always a longitudinal tear in the mucosal membrane or inner lining of the esophagus at the point at which the esophagus meets the stomach (gastroesophageal junction). These tears are named Mallory Weiss tears. These tears tend to be longitudinal, and not circumferential, probably due to the cylindrical shape of the esophagus and stomach. Mallory Weiss syndrome is one of the most common causes of acute bleeding from the upper gastrointestinal tract.

What causes these violent tears?

Esophageal tears occur following any event that can provoke a sudden increase in the intragastric pressure. With an increase in the intragastric pressure, there is a tear at a weak point of the gastrointestinal tract which is usually at the gastroesophageal junction of the esophagus.

Some of the conditions which can provoke a sudden increase in the intragastric pressure include severe vomiting, intense coughing, alcohol binge drinking, chest or abdominal trauma, severe and prolonged hiccups, heavy weight lifting, straining, and convulsions. Bulimic patients following a transesophageal echocardiographic procedure, patients with gastritis which is inflammation of the stomach, and patients with hiatal hernia in which a part of the stomach is pushed up through the diaphragm are also prone to develop a sudden rise of intragastric pressure. Severe vomiting could be caused by migraine or vertigo.

Presentation

The patient comes with a history of hematemesis which is vomiting out blood. The blood is from the torn blood vessels of the injured esophagus. A history of severe vomiting or any condition that could provoke a sudden increase in intragastric pressure is usually present. The patient can also have upper abdominal pain and melena which is the passage of bloody or black colored stools. Most of the patients start to have severe vomiting which later turns into hematemesis. Sometimes patients can present with features of shock that are produced by severe hematemesis. The condition may also be asymptomatic in mild cases.

Diagnosis

The patient history and presenting symptoms are very important as it leads us to the diagnosis of Mallory Weiss syndrome. Any patient presenting to the clinic with specific symptoms like hematemesis, upper abdominal pain, and melena must create a suspicion of Mallory Weiss syndrome in the clinician’s mind. The patient may also have a history of severe vomiting, belching, history of an eating disorder like bulimia, or alcohol binge drinking.

Upper gastrointestinal endoscopy is the gold standard diagnostic tool for esophageal tear. On endoscopy, it is very important to appreciate the visual appearance of the esophageal tear. In Mallory Weiss syndrome, it is more of a linear bleeding laceration close to the gastroesophageal junction of the esophagus. The tear is usually found at 1 o’clock position. In some severe cases, the submucosa can also be involved.

The complete blood count of the patient can show a reduction in red blood cell count as the patient has been bleeding through the gastrointestinal tract for a long time.

What are the treatment options available for Mallory Weiss syndrome?

The good news is that about 90% of the bleeding that is caused by mild esophageal tear stops on its own. So, whenever the bleeding is not severe and the esophageal tear is not very large, no treatment is necessary for the patients. But if the patient has severe blood loss, it is mandatory to start intravenous fluids. Extensive blood loss may even require blood transfusions.

Medications to reduce gastric acid production like proton pump inhibitors or H2 receptor blockers are also given to these patients.

There are also some therapeutic upper endoscopy techniques used to treat Mallory Weiss syndrome. Injection therapy and sclerotherapy can also be done which delivers medicine directly in the tear to close the blood vessels and stop the bleeding. We could also do coagulation therapy which delivers heat to the torn vessel sealing it off.

Surgical care is only required in special cases in which bleeding could not be controlled by therapeutic upper endoscopic intervention or medical therapy. To control and stop the bleeding, esophageal balloon tamponade can be done. This is usually done only in extreme bleeding cases. Esophageal clips can also be applied at sites of active bleeding. In some severe bleeding cases, band ligation is done to arrest bleeding.

References

Authors footnote

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