Mallory-Weiss Syndrome Treatment & Management

An upper endoscopy (performed by a trained pediatric gastroenterologist) should be considered for all patients with persistent bleeding for whom medical therapy is unsuccessful.

Only in extraordinary cases should surgical intervention be required. A consultation with a surgeon should be considered only in patients with persistent bleeding requiring transfusions and in whom the bleeding cannot be controlled by medication or by therapeutic upper endoscopy.

Transfer children with severe uncontrolled bleeding to a tertiary care hospital with an in-house pediatric gastroenterologist.

Once the esophageal bleeding has stopped, no activity restrictions are required.

Mallory-Weiss tears almost never rebleed; thus, follow-up is not usually indicated.

Initial medical management is always supportive. Patients in whom conservative medical therapy is ineffective should have a consultation with a gastroenterologist for possible endoscopy. Note the following:

• Closely monitor vital signs, obtain a CBC count, and place a large-bore intravenous tube for fluid resuscitation.

• Less than 5% of children require a blood transfusion.

• Begin workup to determine the underlying cause of the retching and vomiting.

• In most cases, Mallory-Weiss tears resolve spontaneously; however, consider pharmaceutical therapy in cases of persistent bleeding or complications (see Medication).

• Esophageal balloon tamponade, although useful for patients with esophageal varices, should be considered only in extreme cases because the use of an esophageal balloon increases the risk of extending the esophageal tear.

• Esophageal clips should be applied at the site of active bleeding.

• Endoscopic band ligation has been used and was shown to be an effective and safe procedure for patients with severe bleeding. ^[3]

With the increased availability of certain endoscopic techniques, including mucosal resection, sclerotherapy, and endoscopic retrograde cholangiopancreatography (ERCP), Mallory-Weiss tear has now become a relatively common nosocomial complication of endoscopic procedures. In one study, metallic hemoclips were used to achieve hemostasis among patients presenting with Mallory-Weiss tears. In that study, patients with bleeding Mallory-Weiss tears secondary to endoscopy were compared with patients presenting with Mallory-Weiss tears from other etiologies. In both groups of patients, hemoclips were effective in achieving hemostasis. ^{[10, 12]}

In another study, endoscopic band ligation was compared with hemoclip plus epinephrine injection among patients presenting with upper gastrointestinal bleeding from Mallory-Weiss tears. In 218 consecutive patients with Mallory-Weiss tears, 56 patients required endoscopic hemostasis because of active bleeding. Band ligation was performed in 29 patients, and hemoclip application plus epinephrine injection was performed in 27 patients. Recurrent bleeding occurred in no patients in the banding group and in 18% of patients in the latter group. The investigators concluded that band ligation should be considered as the endoscopic treatment of choice. ^[13]

In a similar comparative study from Korea, no significant difference was noted between hemoclip and band ligation in patients treated with Mallory-Weiss tears, even among those patients treated with comorbid conditions and hemodynamic instability. ^[14] In comparison, a similar small comparative study noted no difference in the efficacy or the safety of band ligation versus epinephrine injection for the treatment of active bleeding in Mallory-Weiss tears. ^[15] Future comparative studies are needed to establish treatment guidelines in patients presenting with Mallory-Weiss tears.

Angiographic embolization of the vessels supplying blood flow to the esophageal tear has been reported in the adult literature but should be considered in children only under dire circumstances.

Two types of endoscopic therapy can be used to control severe bleeding in patients who are hemodynamically unstable because of bleeding from a Mallory-Weiss tear. Note the following:

• Injection therapy is favored as the first-line therapy by most endoscopists for control of bleeding esophageal lesions because of its ease of use, safety, and cost. Typically, the injections are made 3-5 mm apart circumferentially around the site of bleeding in four areas. The chemical agents used for injection therapy include dilute epinephrine, sodium morrhuate, ethyl alcohol, or sodium tetradecyl sulfate.

• Heater probe or bipolar coagulation therapies use electrical current supplied by catheters that can be inserted into an endoscope to control bleeding. Approximately 20 joules (10-15 Watts) of current are used per individual pulse, and treatment is complete when the bleeding has ceased. The current is usually delivered in repeated time-limited pulses.

Evaluate the underlying cause of vomiting; advise patients to avoid identified triggers.

During the acute problem, keep patients on nothing by mouth (NPO). Once resolved, provide the patient clear liquids and advance the diet as tolerated. After complete resolution, no special diet is required. However, foods or liquids that may have been identified as contributing to the cause of the underlying problem (eg, excessive alcohol intake, food allergies) should be avoided.