eMedicine Specialties > Gastroenterology > Esophagus

Mallory-Weiss Tear: Differential Diagnoses & Workup

Author: Louis-Michel Wong Kee Song, MD, Assistant Professor, Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic
Contributor Information and Disclosures

Updated: Apr 16, 2008

Differential Diagnoses

Boerhaave Syndrome
Esophagitis
Gastric Ulcers

Other Problems to Be Considered

Cameron erosions

Workup

Laboratory Studies

• Hemoglobin and hematocrit studies are performed to assess the severity of the initial bleeding episode and to monitor patients.
• Platelet count, prothrombin time, and activated partial thromboplastin time are performed to assess for severe thrombocytopenia and coagulopathy as complicating issues. Coagulation studies are needed in patients on anticoagulants or with minimal or no oral intake while on antibiotics. Platelet count may be low because of alcohol use.
• BUN, creatinine, and electrolyte levels are measured to guide intravenous fluid therapy.
• Blood type and antibody screen are obtained for potential blood transfusions.

Imaging Studies

• Barium or Gastrografin studies should not be performed owing to their low diagnostic sensitivity and interference with endoscopic assessment and therapy.

Other Tests

• Electrocardiogram and cardiac enzymes (if indicated) - To assess for myocardial ischemia related to acute gastrointestinal blood loss, especially in patients with significant anemia, hemodynamic instability, cardiovascular disease, coexisting chest pain, and/or advanced age.

Procedures

• Perform endoscopy early in the clinical course. Endoscopy is the procedure of choice for both diagnosis and therapy.
• Endoscopic diagnosis of a MWT is readily made by identifying active bleeding, an adherent clot, or a fibrin crust over a mucosal split within or near the gastroesophageal junction (see Media file 1).   
  • On average, the split is 2-3 cm in length and a few millimeters in width. Most patients (>80%) present with a single tear.
  • The usual location of the tear is just below the gastroesophageal junction on the lesser curvature of the stomach (between 2 and 6 o'clock on endoscopic viewing with the patient in the left lateral decubitus position).
• MWTs are usually associated with other mucosal lesions. In one study, 83% of patients had additional mucosal abnormalities potentially contributing to bleeding or actually causing retching and vomiting that would induce these tears.
• Several endoscopic modalities are effective for treating a bleeding MWT. The choice usually depends on the endoscopist's familiarity with a particular technique and on equipment availability. Patients with actively bleeding MWTs (ie, arterial spurting, streaming from focal point, diffuse oozing) are treated. Stigmata (eg, nonbleeding visible vessel, adherent clot) do not necessarily require treatment in MWTs as they do in peptic ulcers. Such stigmata usually are not treated unless they are rebleeding episodes from the same lesion or are associated with a coagulopathy. MWTs with a clean, fibrinous base or with flat, pigmented spots are not treated since the risk of rebleeding is minimal.  
  • A contact thermal modality, such as multipolar electrocoagulation (MPEC) or heater probe, with or without epinephrine injection, is typically used to treat an actively bleeding MWT. Effectiveness and safety have been established in only a few randomized, controlled trials. For example, Laine demonstrated greater hemostatic efficacy, fewer emergency interventions, and a trend toward decreased transfusion requirements in favor of MPEC versus sham MPEC.³
  • The MPEC or heater probe is applied on the bleeding point with mild-to-moderate pressure.
    • Suggested treatment parameters for MPEC include a power setting of 14-16 watts (W), 3-4 seconds per application, and 1-5 applications on average.
    • Suggested treatment parameters for heater probe include 15- to 20-J pulses in a sequence of 2-3 pulses. The endpoint is cessation of bleeding and formation of a white coagulum.
  • Epinephrine injection (1:10,000-1:20,000 dilution) reduces or stops bleeding via a mechanism of vasoconstriction and tamponade. It is usually combined with a more definitive therapy (eg, thermal therapy). Aliquots of 0.5-1 mL are injected around and into the bleeding point. No ceiling volume has been identified, and as much as 20 mL of epinephrine have been used. Careful monitoring is required, since submucosal esophageal injection of epinephrine may enter the systemic circulation without a protective first-pass effect, potentially causing serious cardiovascular complications. Epinephrine injection is best avoided in patients with active cardiovascular disease.
  • Successful use of sclerosants, such as alcohol or polidocanol, has been reported. Safer alternatives exist, and sclerosant injection is not recommended by the author because of its potent tissue-damaging effects, risk of deep tissue necrosis, and potential for perforation.
  • Reports on the use of the argon plasma coagulator (APC) in the treatment of bleeding MWTs are limited, but this noncontact device is gaining in popularity owing to its ease of use. In the thin-walled esophagus, the power output should be set at 40-45 W and with a relatively low argon gas flow rate (1 L/min). The APC probe should be maintained 1-2 mm from the target site, which may be difficult to accomplish in the setting of peristalsis.
  • Endoscopic band ligation has been shown to be effective for treating bleeding MWTs. In a small, prospective, randomized study of 34 patients with actively bleeding MWTs, no difference was detected in the efficacy or safety of band ligation versus epinephrine injection. Band ligation should be particularly useful for bleeding MWTs associated with portal hypertension and gastroesophageal varices, in which thermal therapy is not recommended.
  • Endoscopic hemoclipping is also effective for MWTs. The margins of the tear may be approximated, starting at the distal end of the tear and applying successive clips in a cephalad fashion. Alternatively, only the bleeding point can be targeted for hemoclip placement. Optimal deployment of clips may not be achievable because of the tangential location of the tear, or the tear may be too wide. In a study of 26 patients, however, hemoclipping was technically successful in all cases, and the average number of clips used was 2.8 + 1.6 (range, 1-8). In a randomized prospective study of 35 patients with actively bleeding MWTs, hemoclip placement and epinephrine injection were equally effective for achieving primary hemostasis. Whenever feasible, the author favors the use of hemoclips over thermal modalities, as the latter may cause excessive tissue injury leading to necrosis and perforation.
  • Although earlier studies reported balloon tamponade to be beneficial, this technique should probably be avoided, as it recreates the forces that predispose patients to lacerations and may further widen the tear.
• Angiotherapy with either selective vasopressin infusion or embolization of the left gastric artery can be performed in patients who have failed to respond to endoscopic therapy or who are at high risk of endoscopic complications.

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