Mallory-Weiss Tears: Esophageal tear
Mallory-Weiss tears are longitudinal mucosal tears in the esophageal mucosa. It is one of the common causes of acute upper gastrointestinal bleeding, and the gastroesophageal junction (gastric cardia) is the most common site.
The tear is superficial and involves only the mucosal layer, in contrast to Boerhaave's syndrome. Boerhaave's syndrome has full-thickness rupture (the tear involves the muscular layer).
These tears most commonly occur after the period of profuse vomiting, violent coughing, or retching and result in a short period of hematemesis.
The tear is caused by repeated acts of a sudden increase in intraabdominal pressure (IAP). The increased intraabdominal pressure is associated with retching, vomiting, straining, coughing, cardiopulmonary resuscitation (CPR), and blunt abdominal trauma.
Most commonly associated with
- Alcohol abuse (Most common 50-70%)
- Eating disorders associated with forceful retching (bulimia nervosa)
- Food poisoning
- Hiatal hernia
Pathogenesis
The sudden and rapid increase in intraabdominal pressure → Reflux of acid with pressure → Fluid flow shear stress → Longitudinal tear in mucosa → Tear may reach deep into the submucosal arteries and veins → Upper GI bleeding (Hematemesis).
The rapid increase in intraabdominal pressure may happen in-
- forceful and repeated emesis (Bulimia)
- profuse vomiting (alcoholic abuse)
- coughing
- blunt abdominal trauma
Clinical presentation
- Hematemesis- coffee ground appearance / bright red blood
- Epigastric pain
- Melena
Diagnosis
Endoscopy (investigation of choice) – Esophagogastroduodenoscopy
Treatment
Mallory-Weiss tears are generally small and self-limiting tears and have a good prognosis. Presentation with hemorrhagic shock is a possible but rare complication.
Most cases are managed conservatively, interventional or surgical management is rarely needed.
Actively bleeding tear can be treated endoscopically with one of the following -
- Epinephrine injection
- Coaptive coagulation
- Band ligation
- Hemoclips
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