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Mallory-Weiss Syndrome Workup

  • Author: Carmen Cuffari, MD; Chief Editor: Carmen Cuffari, MD  more...
 
Updated: Jun 27, 2016
 

Laboratory Studies

No specific laboratory tests are indicated for determining the etiology of a Mallory-Weiss tear.

  • Obtain a CBC count to determine the severity of bleeding.
  • Coagulation parameters should be assessed.
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Imaging Studies

No specific imaging studies exist that can positively identify an esophageal tear. Several retrospective studies have demonstrated that barium esophagraphy may reveal small esophageal hematomas or thick streaks where the barium becomes trapped in the tear. However, only 20% of patients with a Mallory-Weiss tear had positive radiologic findings, and, in all cases, an upper endoscopy was performed for definitive diagnosis.

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Procedures

See the list below:

  • Esophagogastroduodenoscopy[7]
    • Upper endoscopy is the diagnostic tool for esophageal tears.[8]
    • Visual inspection of the esophagus, stomach, and duodenum is essential in the evaluation of a child presenting with hematemesis.
    • The hallmark of a Mallory-Weiss tear is the visual appearance of one or more linear bleeding lesions at or just proximal to the esophagogastric junction.
    • Perform endoscopy within 24 hours of the bleeding episode.
    • Tears visualized within 24 hours usually have a soft, fresh, mounded, brownish-red appearance on the surface of the mucosa.
    • After 48-72 hours, the tear looks like a mucosal cleft that may be surrounded by erythematous mucosa.
    • By 96 hours, most Mallory-Weiss lesions are well-healed and may be difficult to visualize.
    • In cases of severe bleeding with hemodynamic instability, the patient should be stabilized prior to performing endoscopy.
    • Mallory-Weiss tears can heal quickly after the cessation of vomiting and retching and may not be diagnosed if performance of the upper endoscopy is delayed.
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Staging

Predictive factors for recurrent bleeding include the following:[9]

  • Initial presentation of shock: In a study of 159 patients treated for Mallory-Weiss tears with recurrent bleeding post therapy were in shock at initial manifestation and had active bleeding on endoscopic evaluation.[10]
  • Liver cirrhosis
  • Decreased hemoglobin and platelet count: In a study of 93 patients who were managed for Mallory-Weiss tears, 9 had a fatal outcome. In that study, multivariant analysis showed that advanced age, a low hemoglobin level at clinical presentation, and the presence of tarry stool were associated with an increased risk of dying.[11]
  • Need for blood transfusion
  • Intensive care management
  • Active bleeding noted at the time of endoscopy

Future studies are necessary to validate these clinical observations, and they may perhaps lead to the development of a measure tool for clinical risk among patients presenting with Mallory-Weiss tears.

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Contributor Information and Disclosures
Author

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

B UK Li, MD Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin; Attending Gastroenterologist, Director, Cyclic Vomiting Program, Children’s Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Additional Contributors

Eric S Maller, MD 

Eric S Maller, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, American Society of Transplant Surgeons, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Chris A Liacouras, MD, to the original writing and development of this article.

References
  1. Graham DY, Schwartz JT. The spectrum of the Mallory-Weiss tear. Medicine (Baltimore). 1978 Jul. 57(4):307-18. [Medline].

  2. [Guideline] Millward SF, Bakal CW, Weintraub JL, et al. Treatment of acute nonvariceal gastrointestinal tract bleeding. [online publication]. Reston (VA): American College of Radiology (ACR); 2006. [Full Text].

  3. Harris JM, DiPalma JA. Clinical significance of Mallory-Weiss tears. Am J Gastroenterol. 1993 Dec. 88(12):2056-8. [Medline].

  4. Ljubicic N, Budimir I, Pavic T, Bišcanin A, Puljiz Z, Bratanic A, et al. Mortality in high-risk patients with bleeding Mallory-Weiss syndrome is similar to that of peptic ulcer bleeding. Results of a prospective database study. Scand J Gastroenterol. 2014 Apr. 49(4):458-64. [Medline].

  5. Yu PP, White D, Iannuccilli EA. The Mallory-Weiss syndrome in the pediatric population. Rare condition in children should be considered in the presence of hematemesis. R I Med J. 1982 Feb. 65(2):73-4. [Medline].

  6. Akhtar AJ, Padda MS. Natural history of Mallory-Weiss tear in African American and Hispanic patients. J Natl Med Assoc. 2011 May. 103(5):412-5. [Medline].

  7. Ament ME, Gans L, Christie DK. Experience with esophagogastro-duodenoscopy in diagnosis of 79 pediatric patients with hematemesis, melena or chronic abdominal pain. Gastroenterology. 1975. 68:858-61.

  8. Countryman D, Norwood S, Andrassy RJ. Mallory-Weiss syndrome in children. South Med J. 1982 Nov. 75(11):1426-7. [Medline].

  9. Kerlin P, Bassett D, Grant AK. The Mallory-Weiss lesion: a five-year experience. Med J Aust. 1978 May 6. 1(9):471-3. [Medline].

  10. Kim JW, Kim HS, Byun JW, et al. Predictive factors of recurrent bleeding in Mallory-Weiss syndrome. Korean J Gastroenterol. 2005 Dec. 46(6):447-54. [Medline].

  11. Fujisawa N, Inamori M, Sekino Y, Akimoto K, Iida H, Takahata A, et al. Risk factors for mortality in patients with Mallory-Weiss syndrome. Hepatogastroenterology. Apr/2011. 58:417-20. [Medline].

  12. Ivekovic H, Radulovic B, Jankovic S, Markos P, Rustemovic N. Combined use of clips and nylon snare ("tulip-bundle") as a rescue endoscopic bleeding control in a mallory-weiss syndrome. Case Rep Gastrointest Med. 2014. 2014:972765. [Medline]. [Full Text].

  13. Lecleire S, Antonietti M, Iwanicki-Caron I, et al. Endoscopic band ligation could decrease recurrent bleeding in Mallory-Weiss syndrome as compared to haemostasis by hemoclips plus epinephrine. Aliment Pharmacol Ther. 2009 Aug 15. 30(4):399-405. [Medline].

  14. Cho YS, Chae HS, Kim HK, et al. Endoscopic band ligation and endoscopic hemoclip placement for patients with Mallory-Weiss syndrome and active bleeding. World J Gastroenterol. 2008 Apr 7. 14(13):2080-4. [Medline]. [Full Text].

  15. Park CH, Min SW, Sohn YH, et al. A prospective, randomized trial of endoscopic band ligation vs. epinephrine injection for actively bleeding Mallory-Weiss syndrome. Gastrointest Endosc. 2004 Jul. 60(1):22-7. [Medline].

  16. Kelly JA. Mallory-Weiss tear. Altschuler SM, Liacouras CA, eds. Clinical Pediatric Gastroenterology. Philadelphia, Pa: Chuchill-Livingstone; 1999. 303-5.

  17. Higuchi N, Akahoshi K, Sumida Y, et al. Endoscopic band ligation therapy for upper gastrointestinal bleeding related to Mallory-Weiss syndrome. Surg Endosc. 2006 Sep. 20(9):1431-4. [Medline].

  18. Shimoda R, Iwakiri R, Sakata H, et al. Endoscopic hemostasis with metallic hemoclips for iatrogenic Mallory-Weiss tear caused by endoscopic examination. Dig Endosc. 2009 Jan. 21(1):20-3. [Medline].

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Mallory-Weiss tear. Typical longitudinal mucosal tear with overlying fibrinous exudate extending from the distal esophagus to the gastric cardia. Courtesy of C.J. Gostout, MD.
Mallory-Weiss tear. Retroflexed view of the cardia showing the typical location of the tear with a clean base.
 
 
 
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