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Mallory–Weiss syndrome

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Mallory–Weiss syndrome
Other namesGastro-esophageal laceration syndrome
Mallory–Weiss tear affecting the esophageal side of the gastroesophageal junction
SpecialtyGastroenterology Edit this on Wikidata

Mallory–Weiss syndrome is a condition where high intra-abdominal pressures causes laceration and bleeding of the gastrointestinal submucosa called Mallory-Weiss tears.[1][2] Additionally, Mallory-Weiss syndrome is considered one of the most common causes of acute upper gastrointestinal bleeding (UGI bleeding), and counts for around 1-15% of all cases in adults and less than 5% in children.[1] It has been found that tears are up to 2 to 4 times more prevalent in men than women.[1] The tears can cause upper gastrointestinal bleeding and predominantly occur where the esophagus meets the stomach (gastroesophageal junction).[1] However, the tears can happen anywhere from the middle of the esophagus to the cardia of the stomach.[1] Mallory-Weiss syndrome is often caused by persistent severe vomiting and or retching from alcoholism or bulimia nervosa.[1] Gastroesophageal reflux disease (GERD) is another risk factor that is often linked with Mallory-Weiss syndrome.[1] However, not every individual with Mallory-Weiss syndrome will have these risk factors.[1] Individuals with Mallory-Weiss syndrome will have hematemesis (vomiting up blood), however the symptoms can vary. [1]

Signs and symptoms

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Mallory–Weiss syndrome often presents as an episode of vomiting up blood (hematemesis) after violent retching or vomiting[3], but may also be noticed as old blood in the stool (melena), and a history of retching may be absent. Additional symptoms can occur depending on how severe the condition is. Some individuals have experienced dizziness, loss of consciousness, and upper abdomen pain.[1]

In cases of more severe bleeding, the typical symptoms of Mallory-Weiss Syndrome are those typical found in shock, which can be life-threatening.[1] If a patient does happen to go into shock it may be reversed if discovered early.[4] Although there are multiple types of shock, hemorrhagic hypovolemic shock is most commonly associated with gastrointestinal bleeding.[4] Furthermore, gastrointestinal losses, such as those incurred from prolonged vomiting or diarrhea are associated with non-hemorrhagic hypovolemic shock. [4] Both hemorrhagic and non-hemorrhagic hypovolemic shock can occur when there are decreases in intravascular volume, such as when the body is hemorrhaging (bleeding) and or significant fluid loss. This loss of fluid causes there to be a decrease in intravascular volume which causes a subsequent reflex mechanism produced by the body to activate SANs (sympathetic nervous system) in the later stages of hypovolemic shock.[4] SANs is activated in response to the drop in mean arterial pressure that is brought on by the loss of fluid. There are three stages of shock which include pre-shock, shock, and then end-organ failure.[4] During pre-shock, the body is starting to compensate for the loss of fluid, typical symptoms during this stage include tachycardia (rapid heart rate), hypotension (low blood pressure), tachypnea (rapid shallow breathing), or even changes in mental status.[4] The second stage of shock is when there starts to be end-organ damage, this occurs when the compensatory mechanism it inadequate. Finally, the last stage of shock is when there is end-organ damage which is often irreversible and can lead to death.

In most cases of Mallory-Weiss Syndrome, the hemorrhage (bleeding) will typically stop spontaneously after about 48–72 hours.[1] With this being said, sometimes endoscopic or surgical treatment are sometimes required. Due to the advances in treatment options for acute hemorrhage and hypovolemic shock, mortality of Mallory-Weiss Syndrome has dramatically decreased.[1]

Causes

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It is often associated with alcoholism[5], eating disorders such as bulimia nervosa, and gastroesophageal reflux disease (GERD).[1] It is thought that Mallory-Weiss syndrome can be caused by actions that cause sudden increases in intra-abdominal pressure, such as repeated severe vomiting or coughing.[1] There is some conflicting evidence that the presence of a hiatal hernia could be a predisposing condition to developing Mallory-Weiss syndrome.[6] There is conflicting data suggesting the association between hiatal hernias and Mallory-Weiss syndrome. In 1989, a study conducted in Japan set out to determine if there was a link to Mallory-Weiss syndrome and hiatal hernias, this study found that hiatial hernias were found in 75% of patients with Mallory-Weiss syndrome.[7] On the contrary, a case-control study in 2017 found there was no association between hiatal hernias and Mallory-Weiss syndrome.[6] Forceful vomiting causes tearing of the mucosa at the junction. Additionally, the use of NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen, are known to increase the risk of upper gastrointestinal bleeding.[8] NSAIDs can increase the risk of upper gastrointestinal bleeding because they can cause further damage to the intestinal submucosa by inhibiting prostaglandin synthesis.[8] Prostaglandins are important for maintaining the health of the intestinal submucosa in a variety of ways such as inhibiting gastric acid secretion, and allow there proper blood supply.[9] NSAID abuse is also a rare association.[10] In rare instances some chronic disorders like Ménière's disease that cause long term nausea and vomiting could be a factor.

Additionally, bleeding from Mallory-Weiss tears is often associated with individuals who have a history of portal hypertension and esophageal varices.[1] Portal hypertension is where there is increased pressure within the venous portal system.[11] Additionally, studies that were preformed in patients with cirrhosis (scaring/fibrosis of the liver) who also had portal hypertension have shown that an increase in portal pressure can cause an increase in intra-abdominal pressure. [12] These increases in intra-abdominal pressure are associated with Mallory-Weiss Syndrome. More severe upper gastrointestinal bleeds are associated with concurrent portal hypertension and esophageal varices. [1] The formation of esophageal varices (dilated veins) is linked to the presence of portal hypertension.[13] Additionally, esophageal varices can rupture which can be fatal.[13]

The tear involves the mucosa and submucosa but not the muscular layer (contrast to Boerhaave syndrome which involves all the layers).[14] Most patients are between the ages of 30 and 50 years, although it has been reported in infants aged as young as 3 weeks, as well as in older people.[15][16] Hyperemesis gravidarum, which is severe morning sickness associated with vomiting and retching in pregnancy, is also a known cause of Mallory–Weiss tear.[17]

There have been a few complications from invasive procedures such as trans-esophageal echocardiography and upper gastrointestinal endoscopy that cause Mallory-Weiss tears called Iatrogenic Mallory-Weiss syndrome.[1] However, it is infrequent since it only occurs in 0.07% to 0.49% of individuals who have received the upper gastrointestinal endoscopy procedure.[1]

Diagnosis

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Definitive diagnosis of Mallory-Weiss tears is by upper gastrointestinal (GI) endoscopy of the esophagus and stomach.[1][18] Typically, the tear is located near the top of the stomach's lesser curvature and below the gastroesophageal junction. In the majority of patients, tears usually range from approximately 2 to 4 cm in length. The findings may include indications of active bleeding or the presence of clot over the tear. [1] To determine if the patient has active bleedings or signs of chronic alcoholism that can precede Mallory-Weiss syndrome, the patient's lab values would be obtained to get a complete blood count (CBC) including hematocrit & hemoglobin levels alongside platelet count. [19]

Additionally, diagnosis of Mallory-Weiss Syndrome includes elimination of other causes of a upper gastrointestinal bleed.

As stated above, hypovolemic shock can occur in Mallory-Weiss Syndrome due to hemorrhaging or other forms of fluid loss. When diagnosing Mallory-Weiss Syndrome it is important to clinicians to look at symptoms of shock.

Proper history taking by the medical doctor to distinguish other conditions that cause haematemesis but definitive diagnosis is by conducting esophagogastroduodenoscopy, which is a procedure that allows the oropharynx, esophagus, stomach, and proximal doudenum (beginning of the small intestine) to be visualized.[20][21][22][23]

Treatment

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Often, Mallory-Weiss tears can heal on their own, however, endoscopic hemostasis techniques are necessary for constant bleeding.[2] Additionally, patients that develop and heal from Mallory-Weiss Syndrome often do not have recurrence of the tears. Two examples of endoscopic hemostasis techniques are hemoclipping and heater probe thermocoagulation.[2] Hemoclipping is an effective method for treating Mallory-Weiss tears because it uses small metal clips, which cause minimal tissue damage and stop the bleeding by clipping the affected blood vessels.[24] A heat probe is another technique used to stop bleeding by applying it directly on the area of the active bleed to start the coagulation.[25] Treatment is usually supportive as persistent bleeding after endoscopic treatment or esophagogastroscopy is uncommon. However cauterization or injection of epinephrine[26] to stop the bleeding through vasoconstriction may be undertaken during the index endoscopy procedure in the case of active and recurrent bleeding. Because it is easy to implement and widely available, such injection methods to stop bleeding are commonly used.[27] Some other options to stop bleeding include ethanol injections, ε-aminocaproic acid,[27] Multipolar electrocoagulation (MPEC), or Argon plasma coagulation (APC).[1] When endoscopy is ineffective, angiography or embolization of the arteries supplying the region may be required to stop the bleeding.

If all other methods fail, high gastrostomy can be used to ligate the bleeding vessel. A Sengstaken-Blakemore tube will not be able to stop bleeding as here the bleeding is arterial and the pressure in the balloon is not sufficient to overcome the arterial pressure.

In pharmacological treatment, Proton pump inhibitors (such as omeprazole, pantoprazole) and H2 receptor antagonist (such as famotidine) are utilized to manage and lower gastric acidity. Decreasing the acidity through use of proton pump inhibitors and H2 receptor antagonists allows there to be time for healing.[1] Additionally, antiemetics such as promethazine are given to control nausea and vomiting as part of the treatment regimen. [1]

History

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Mallory-Weiss syndrome was named after G. Kenneth Mallory and Soma Weiss who accurately characterized the condition as a lower esophageal laceration in 1929. Before 1929, there were cases reported with similar symptoms of bleeding in the esophagus, first being Johann Friedrich Hermann Albers reporting ulcer in the lower esophagus in 1833, however those were caused by ulcers and not lacerations. [1][28] Another instance of Mallory-Weiss syndrome was from 1879 when Dr. Heinrich Quincke discovered 3 cases of bleeding from the formation of ulcers in the gastroesophageal tube; 2 of the cases were fatal due to vomiting of blood.[29][30]

See also

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References

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  1. ^ a b c d e f g h i j k l m n o p q r s t u v w x y Rawla P, Devasahayam J (2024). "Mallory-Weiss Syndrome". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 30855778. Retrieved 2024-07-23.
  2. ^ a b c Tanabe S, Saigenji K (September 1998). "[Mallory-Weiss syndrome]". Nihon Rinsho. Japanese Journal of Clinical Medicine. 56 (9): 2332–2335. PMID 9780715.
  3. ^ Lee SH, Yoon C, Chai DG, et al. Mallory-Weiss Syndrome: Retrospective Review of Ten Years’ Experience. Gastrointestinal Endoscopy. 2006;63(5):AB132. doi:https://doi.org/10.1016/j.gie.2006.03.217‌
  4. ^ a b c d e f Haseer Koya H, Paul M (2024), "Shock", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 30285387, retrieved 2024-07-25
  5. ^ Caroli A, Follador R, Gobbi V, Breda P, Ricci G (1989). "[Mallory-Weiss syndrome. Personal experience and review of the literature]". Minerva Dietologica e Gastroenterologica (in Italian). 35 (1): 7–12. PMID 2657497.
  6. ^ a b Corral JE, Keihanian T, Kröner PT, Dauer R, Lukens FJ, Sussman DA (April 2017). "Mallory Weiss syndrome is not associated with hiatal hernia: a matched case-control study". Scandinavian Journal of Gastroenterology. 52 (4): 462–464. doi:10.1080/00365521.2016.1267793. PMID 28007004.
  7. ^ Sato H, Takase S, Takada A (1989). "The association of esophageal histus hernia with Mallory-Weiss syndrome". Gastroenterologia Japonica. 24 (3): 233–238. doi:10.1007/BF02774319. PMID 2744343.
  8. ^ a b Mellemkjaer L, Blot WJ, Sørensen HT, Thomassen L, McLaughlin JK, Nielsen GL, et al. (February 2002). "Upper gastrointestinal bleeding among users of NSAIDs: a population-based cohort study in Denmark". British Journal of Clinical Pharmacology. 53 (2): 173–181. doi:10.1046/j.0306-5251.2001.01220.x. PMC 1874281. PMID 11851641.
  9. ^ Wallace JL (2008-10). "Prostaglandins, NSAIDs, and Gastric Mucosal Protection: Why Doesn't the Stomach Digest Itself?". Physiological Reviews. 88 (4): 1547–1565. doi:10.1152/physrev.00004.2008. ISSN 0031-9333. {{cite journal}}: Check date values in: |date= (help)
  10. ^ Eslava García R, Negrete Pardo JL, Muñoz Kim P, García S (April 1990). "[Mallory-Weiss syndrome. Surgical treatment after sclerotherapy. Presentation of a case and review of the literature]". Revista de Gastroenterologia de Mexico. 55 (2): 75–77. PMID 2287873.
  11. ^ Oliver TI, Sharma B, John S (2024). "Portal Hypertension". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 29939540. Retrieved 2024-07-24.
  12. ^ Escorsell A, Ginès A, Llach J, García-Pagán JC, Bordas JM, Bosch J, et al. (October 2002). "Increasing intra-abdominal pressure increases pressure, volume, and wall tension in esophageal varices". Hepatology. 36 (4 Pt 1): 936–940. doi:10.1053/jhep.2002.35817. PMID 12297841.
  13. ^ a b Meseeha M, Attia M (2024), "Esophageal Varices", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 28846255, retrieved 2024-07-25
  14. ^ Boerhaave Syndrome at eMedicine
  15. ^ Bak-Romaniszyn L, Małecka-Panas E, Czkwianianc E, Płaneta-Małecka I (1999-03-01). "Mallory-Weiss syndrome in children". Diseases of the Esophagus. 12 (1): 65–67. doi:10.1046/j.1442-2050.1999.00006.x. PMID 10941865.
  16. ^ Kitagawa T, Takano H, Sohma M, Mutoh E, Takeda S (May 1994). "[Clinical study of Mallory-Weiss syndrome in the aged patients over 75 year--mainly five cases induced by the endoscopic examination]". Nihon Ronen Igakkai Zasshi. Japanese Journal of Geriatrics. 31 (5): 374–379. doi:10.3143/geriatrics.31.374. PMID 8072208.
  17. ^ Parva M, Finnegan M, Keiter C, Mercogliano G, Perez CM (August 2009). "Mallory-Weiss tear diagnosed in the immediate postpartum period: a case report". Journal of Obstetrics and Gynaecology Canada. 31 (8): 740–743. doi:10.1016/S1701-2163(16)34280-3. PMID 19772708.
  18. ^ Hastings PR, Peters KW, Cohn I (November 1981). "Mallory-Weiss syndrome. Review of 69 cases". American Journal of Surgery. 142 (5): 560–562. doi:10.1016/0002-9610(81)90425-6. PMID 7304810.
  19. ^ Rawla P, Devasahayam J (2024). "Mallory-Weiss Syndrome". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 30855778. Retrieved 2024-07-23.
  20. ^ "Gastroscopy – examination of oesophagus and stomach by endoscope". BUPA. December 2006. Archived from the original on 2007-10-06. Retrieved 2007-10-07.
  21. ^ "Upper Endoscopy". National Digestive Diseases Information Clearinghouse. National Institutes of Health. November 2004. Archived from the original on 2007-10-24. Retrieved 2007-10-07.
  22. ^ "What is Upper GI Endoscopy?". Patient Center -- Procedures. American Gastroenterological Association. Archived from the original on 2007-09-28. Retrieved 2007-10-07.
  23. ^ Ahlawat R, Hoilat GJ, Ross AB (2024). "Esophagogastroduodenoscopy". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 30335301. Retrieved 2024-07-24.
  24. ^ Xavier AT, Campos JF, Robinson L, Lima EJ, da Rocha LC, Arantes VN (2020). "Endoscopic clipping for gastrointestinal bleeding: emergency and prophylactic indications". Annals of Gastroenterology. 33 (6): 563–570. doi:10.20524/aog.2020.0526. PMC 7599350. PMID 33162733.
  25. ^ Kovacs TO, Jensen DM (1987). "Endoscopic control of gastroduodenal hemorrhage". Annual Review of Medicine. 38: 267–277. doi:10.1146/annurev.me.38.020187.001411. PMID 3555295.
  26. ^ Gawrieh S, Shaker R (June 2005). "Treatment of actively bleeding Mallory-Weiss syndrome: epinephrine injection or band ligation?". Current Gastroenterology Reports. 7 (3): 175. doi:10.1007/s11894-005-0030-0. PMID 15913474. S2CID 195343875.
  27. ^ a b Cherednikov EF, Kunin AA, Cherednikov EE, Moiseeva NS (March 2016). "The role of etiopathogenetic aspects in prediction and prevention of discontinuous-hemorrhagic (Mallory-Weiss) syndrome". The EPMA Journal. 7 (1): 7. doi:10.1186/s13167-016-0056-4. PMC 4799841. PMID 26998186.
  28. ^ Carr JC (January 1973). "The Mallory-Weiss Syndrome". Clinical Radiology. 24 (1): 107–112. doi:10.1016/S0009-9260(73)80127-8. PMID 4579296.
  29. ^ Ansari, A. (1984). Mallory-Weiss syndrome: Experience in a community hospital. Postgraduate Medicine, 76(8), 189–198. https://doi.org/10.1080/00325481.1984.11698826
  30. ^ Carr JC. The Mallory-Weiss Syndrome. Clin Radiol. 1973 Jan;24(1):107-12. doi: 10.1016/s0009-9260(73)80127-8. PMID: 4579296.
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