History

Fact Explanation
Hematemesis Patients with esophageal laceration can present with hematemesis. In gastroesophageal laceration-hemorrhage syndrome (Mallory-Weiss tear) there is a longitudinal laceration of the gastroesophageal junction or at the level of gastric cardia. Mallory-Weiss tears account for about 5%-15% of upper gastrointestinal bleeding. [1,3]
Prolonged vomiting Prolonged retching and vomiting, as well as straining, hiccupping and coughing carry a risk of developing Mallory-Weiss tear. Hyperemesis gravidarum, chemotherapy, digoxin toxicity, renal failure and advanced malignancy are also causative factors of severe vomiting and Mallory-Weiss tears. [1,4]
Melena Patients may not develop hematemesis instead present with malena (black colored, tarry like foul smelling stools) due to upper gastrointestinal hemorrhage.
Hematochezia Hematochezia is the passage of fresh blood per rectum. This is an ominous sign and indicates severe upper gastrointestinal hemorrhage. Patients develop hematochezia because the rate and amount of bleeding is so high and the gastrointestinal enzymes cannot digest and degrade the bleed. This can be often life-threatening and patients can present with postural dizziness, syncope or collapse. [5]
Alcoholism Patients who are addicted to alcohol and heavy alcohol users are at risk of developing Mallory-Weiss tears. [1]
History of trauma Patients may have a history of blunt abdominal trauma which causes the gastroesophageal junction laceration. Cardiopulmonary resuscitation also carries a risk of developing Mallory-Weiss tears. [6]
History of hiatal hernia During episodes of retching or vomiting the intra-abdominal pressure increases significantly, creating increased pressure gradient between the abdominal and thoracic cavities. If a hiatal hernia is present shearing forces develop across the hiatal hernia causing mucosal lacerations. Such lacerations are common over the lesser curvature of the stomach because of its relative immobility. [7]
History of upper gastrointestinal endoscopy (UGIE) UGIE carries a small risk of iatrogenic Mallory-Weiss tears. The risk is higher if the patient develops retching during the procedure. The risk is about 0.007%-0.49%. Patients develop Mallory-Weiss tears even after transesophageal endoscopy and endoscopic submucosal dissection as well. [1,2]
References
  1. HONGOU H, FU K, UEYAMA H, TAKAHASHI T, TAKEDA T, MIYAZAKI A, WATANABE S. Mallory-Weiss tear during gastric endoscopic submucosal dissection World J Gastrointest Endosc [online] 2011 Jul 16, 3(7):151-153 [viewed 10 August 2014] Available from: doi:10.4253/wjge.v3.i7.151
  2. FUJII HIROMICHI, SUEHIRO SHIGEFUMI, SHIBATA TOSHIHIKO, AOYAMA TAKANOBU, IKUTA TAKESHI. Mallory - Weiss Tear Complicating Intraoperative Transesophageal Echocardiography. Circ J [online] 2003 December, 67(4):357-358 [viewed 10 August 2014] Available from: doi:10.1253/circj.67.357
  3. LIM C, EVERETT S. Oesophageal haematoma and associated Mallory-Weiss tear Postgrad Med J [online] 2004 Dec, 80(950):734-735 [viewed 10 August 2014] Available from: doi:10.1136/pgmj.2003.018432
  4. PALMER K. Management of haematemesis and melaena. Postgraduate Medical Journal [online] 2004 July, 80(945):399-404 [viewed 10 August 2014] Available from: doi:10.1136/pgmj.2003.017558
  5. SITTICHANBUNCHA YUWARES, SENASU SUTHASINEE, THONGKRAU THEERAYUT, KEERATIKASIKORN CHAIYAPON, SAWANYAWISUTH KITTISAK. How to Differentiate Sites of Gastrointestinal Bleeding in Patients with Hematochezia by Using Clinical Factors?. Gastroenterology Research and Practice [online] 2013 December, 2013:1-5 [viewed 10 August 2014] Available from: doi:10.1155/2013/265076
  6. LIM C H. Oesophageal haematoma and associated Mallory-Weiss tear. Postgraduate Medical Journal [online] 2004 December, 80(950):734-735 [viewed 10 August 2014] Available from: doi:10.1136/pgmj.2003.018432
  7. CRAFT IL. Hiatus hernia and Mallory-Weiss syndrome. Postgrad Med J [online] 1967 Sep, 43(503):609-611 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2466204

Examination

Fact Explanation
Tachycardia Patients with significant bleeding (more than 15% of the total blood volume) can develop tachycardia. [1]
Blood pressure Increase in both systolic and diastolic blood pressure can be observed in grade II hemorrhage (15% to 30% of the total blood volume). Blood pressure is low in grade III hemorrhage (30% TO 40% of the total blood volume) and unrecordable in grade IV (more than 40% of the total blood volume). [1]
Cold clammy extremities Patients develop cold clammy extremities due to peripheral vasoconstriction, which develops as a compensatory mechanism of hemorrhage. [1]
Capillary refill time Capillary refill time is prolonged (more than 2 seconds) in patients with hemorrhage and it is a sign of peripheral hypoperfusion.
Altered mental status Patients develop altered mental status, with grade III and IV hemorrhages.
References
  1. EL SAYAD MOHAMED, NOUREDDINE HUSSEIN. Recent Advances of Hemorrhage Management in Severe Trauma. Emergency Medicine International [online] 2014 December, 2014:1-5 [viewed 10 August 2014] Available from: doi:10.1155/2014/638956

Differential Diagnoses

Fact Explanation
Boerhaave syndrome Boerhaave syndrome refers to a transmural tear of the distal oesophagus. This is induced by a sudden increase in intramural pressure of the esophagus. Patients present with classic triad of vomiting, abdominal or chest pain, and subcutaneous emphysema. [2]
Esophagitis Esophagitis is another cause for coffee-ground vomiting. Endoscopic examination shows inflammatory changes of the esophagus. [1]
Gastric ulcers Patients with gastric ulcers present with burning epigastric pain and can develop coffee ground vomiting. [3]
Cameron erosions Cameron erosions refers to linear erosions on the crest of gastric folds. This can also present with hematemesis and melena. [4]
Thrombocytopenia Patients with thrombocytopenia can also develop spontaneous upper gastrointestinal vomiting. Reduced platelet counts can be seen in the full blood count.
References
  1. PALMER K. Management of haematemesis and melaena. Postgraduate Medical Journal [online] 2004 July, 80(945):399-404 [viewed 10 August 2014] Available from: doi:10.1136/pgmj.2003.017558
  2. SPAPEN J., DE REGT J., NIEBOER K., VERFAILLIE G., HONORĂ© P. M., SPAPEN H.. Boerhaave's Syndrome: Still a Diagnostic and Therapeutic Challenge in the 21st Century. Case Reports in Critical Care [online] 2013 December, 2013:1-4 [viewed 10 August 2014] Available from: doi:10.1155/2013/161286
  3. ARO P.. Peptic Ulcer Disease in a General Adult Population: The Kalixanda Study: A Random Population-based Study. American Journal of Epidemiology [online] 2006 April, 163(11):1025-1034 [viewed 10 August 2014] Available from: doi:10.1093/aje/kwj129
  4. Gastrointestinal: Cameron's erosions. J Gastroenterol Hepatol [online] 2002 March, 17(3):343-343 [viewed 10 August 2014] Available from: doi:10.1046/j.1440-1746.2002.02760.x

Investigations - for Diagnosis

Fact Explanation
Upper gastrointestinal endoscopy (UGIE) UGIE can visualize the presence of longitudinal mucosal tear. In addition UGIE is helpful in detecting active bleeding, and presence of blood clots. [1]
References
  1. CHO YS, CHAE HS, KIM HK, KIM JS, KIM BW, KIM SS, HAN SW, CHOI KY. Endoscopic band ligation and endoscopic hemoclip placement for patients with Mallory-Weiss syndrome and active bleeding. World J Gastroenterol [online] 2008 Apr 7, 14(13):2080-4 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18395910

Investigations - Fitness for Management

Fact Explanation
Full blood count Patients with significant bleeding have low hemoglobin levels. Compensatory hemoconcentration results in low packed cell volume.
Renal function test Patients with significant hemorrhage are at risk of developing pre-renal renal failure. Elevated serum creatinine and altered electrolyte concentrations are indicative of renal failure.
ECG Hypovolemia and hypotension can induce myocardial ischemia.
References

Management - General Measures

Fact Explanation
Fluid resuscitation Intravenous fluid resuscitation is necessary for patients with estimated fluid loss of more than 15%. Crystalloids are preferred over colloids. These expand the intravascular volume. Crossmatched blood transfusion is necessary for severe hemorrhage. [1,2]
References
  1. CHO YS, CHAE HS, KIM HK, KIM JS, KIM BW, KIM SS, HAN SW, CHOI KY. Endoscopic band ligation and endoscopic hemoclip placement for patients with Mallory-Weiss syndrome and active bleeding. World J Gastroenterol [online] 2008 Apr 7, 14(13):2080-4 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18395910
  2. EL SAYAD MOHAMED, NOUREDDINE HUSSEIN. Recent Advances of Hemorrhage Management in Severe Trauma. Emergency Medicine International [online] 2014 December, 2014:1-5 [viewed 10 August 2014] Available from: doi:10.1155/2014/638956

Management - Specific Treatments

Fact Explanation
Conservative management Patients who are hemodynamically stable, and no active bleeding on UGIE can be managed conservatively. These patients should be observed in the hospital for at least 24 hours. Patients with low risk of re-bleeding can be on liquid diet and start solids after 48 hours. Patients with significant risk of re-bleeding (endoscopic evidence of spurting vessels, diffuse bleeding or adherent clot) should be treated. [1,2]
Endoscopic thermal coagulation Hemostats can be achieved with endoscopic thermal coagulation of the bleeding vessels. [1]
Endoscopic injection of epinephrine Endoscopic injection of epinephrine is indicated for the treatment of active bleeding from Mallory-Weiss tears for patients without cardiovascular comorbidities (ventricular tachycardia, ischemic heart disease). [2]
Endoscopic injection of sclerosants Endoscopic injection of sclerosant (alcohol or polidocanol) can be used for the treatment of active bleeding from the Mallory-Weiss tears. [2]
Argon plasma coagulation Argon plasma coagulation is also indicated for patients with Mallory-Weiss tears. [3]
Endoscopic clipping Endoscopic clipping of the bleeding vessel is a novel mode of treatment of bleeding Mallory-Weiss tears. [1,2]
Endoscopic banding Banding of the bleeding vessels is another effective treatment option. Endoscopic clipping and banding are equally effective in achieving hemostasis. [2]
Angiotherapy If the initial endoscopic treatment modalities fail in achieving hemostasis, selective embolization or epinephrine injection of the bleeding vessel can be done. [2]
Surgery Oversewing of the mucosal laceration should be done if both endoscopic treatment and angiotherapy failed. [2]
Balloon tamponade Placement of a inflatable balloon in the lower esophagus can be used to control bleeding with direct pressure. However its use is limited due to the belief that esophageal distension may worsen bleeding. [2]
References
  1. HONGOU H, FU K, UEYAMA H, TAKAHASHI T, TAKEDA T, MIYAZAKI A, WATANABE S. Mallory-Weiss tear during gastric endoscopic submucosal dissection World J Gastrointest Endosc [online] 2011 Jul 16, 3(7):151-153 [viewed 10 August 2014] Available from: doi:10.4253/wjge.v3.i7.151
  2. CHO YS, CHAE HS, KIM HK, KIM JS, KIM BW, KIM SS, HAN SW, CHOI KY. Endoscopic band ligation and endoscopic hemoclip placement for patients with Mallory-Weiss syndrome and active bleeding. World J Gastroenterol [online] 2008 Apr 7, 14(13):2080-4 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18395910
  3. PALMER K. Management of haematemesis and melaena. Postgraduate Medical Journal [online] 2004 July, 80(945):399-404 [viewed 10 August 2014] Available from: doi:10.1136/pgmj.2003.017558