PANCE Blueprint GI and Nutrition (9%)

Mallory Weiss tear

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Patient will present as → a 21-year-old male with hematemesis. He is brought by his girlfriend who reports that he and his buddies have been out drinking every night last week in celebration of his 21st birthday. He reports having vomited each night, but tonight when he started vomiting, he noticed that there was streaking of blood. Concerned, he decided to come to the emergency department.

What causes Mallory-Weiss tears?
Forced vomiting or retching (often involving alcohol)

A Mallory-Weiss tear is a linear mucosal tear in the esophagus at the gastroesophageal junction

  • Mallory-Weiss tears are the cause of 5-10% of all acute upper GI bleeds
  • Patient with a history of alcohol intake and an episode of vomiting with blood
Mallory-Weiss tear at the junction of the esophagus and stomach

Mallory-Weiss tear at the junction of the esophagus and stomach

Diagnosed with upper endoscopy showing superficial longitudinal mucosal erosions

Generally self limiting and no need for treatment

mallory-weiss_5735_1477883794 (1) Mallory-Weiss syndrome describes mucosal lacerations, leading to bleeding at the junction of the stomach and esophagus. This often results from forceful vomiting, which may be a consequence of eating disorders or alcoholism. Diagnosis is made through endoscopy, through which treatment (if needed) can also take place.

Mallory-Weiss Picmonic

Question 1
A 46-year old man presented at the ED with hematemesis following excessive retching and vomiting after having alcohol binge. He’s hemodynamically stable and there is no fever. Which of the following is the most likely diagnosis?
A
Boerhaave syndrome
Hint:
Boerhaave syndrome is a full thickness tear/rupture of the distal esophagus following persistent retching and vomiting with recent excessive alcohol intake. There is usually associated sudden onset severe chest pain, fever, patient may be in shock, and subcutaneous emphysema.
B
Mallory-weiss tear
C
Bleeding esophageal varices
Hint:
Bleeding esophageal varices occur as a result of decompensating chronic liver disease.
D
Bleeding Peptic ulcer disease (PUD)
Hint:
Bleeding PUD does occur following vomiting and retching. There may be history chronic NSAID ingestion, epigastric pain associated with meals. Patient may be known to have PUD.
Question 1 Explanation: 
Mallory-weiss tear is characterized by upper GI bleeding secondary to longitudinal mucosal laceration just below the gastroesophageal junction. It occurs after any event that provokes a sudden rise in intragastric pressure. Persistent retching and vomiting following alcohol binge can cause this. Some hematemesis can occur after a single episode of vomiting/retching.
Question 2
Concerning the patient described above, what investigative modality is required to confirm the diagnosis?
A
Chest X-ray
Hint:
Chest X-ray plays no role in diagnosing Mallory-weiss tear.
B
Barium swallow
Hint:
Barium swallow plays no role in diagnosing Mallory-weiss tear.
C
Barium meal
Hint:
Chest X-ray plays no role in diagnosing Mallory-weiss tear.
D
Esophagogastroscopy
Question 2 Explanation: 
Esophagogastroscopy is used to make a definitive diagnosis of Mallory-weiss tear and also for treating it if indicated.
Question 3
Which of the following is not a cause of upper gastrointestinal bleeding?
A
Mallory-Weiss syndrome
Hint:
Mallory-Weiss syndrome can cause upper gastrointestinal bleeding.
B
Gastritis
Hint:
Gastritis can cause upper gastrointestinal bleeding.
C
PUD
Hint:
PUD can cause upper gastrointestinal bleeding.
D
Diverticulosis
Question 3 Explanation: 
Diverticulosis is a cause of lower gastrointestinal bleeding
Question 4
Which of the following is not an endoscopic modality in treating bleeding Mallory-weiss tear?
A
Sclerosant injection
Hint:
Sclerosant injection is done endoscopically.
B
Band ligation
Hint:
Band ligation is done endoscopically.
C
Angiotherapy
D
Hemoclip placement
Hint:
Hemoclip placement is done endoscopically.
Question 4 Explanation: 
Angiotherapy is a treatment modality for bleeding Mallory-weiss syndrome. Performed in patient whose lesion failed to respond to endoscopic therapy. Done either by intraarterial vasopressin infusion or arterial embolisation.
Question 5
Which of the following is not a precipitating factor for Mallory-weiss tear?
A
Sneezing
B
Blunt abdominal trauma
Hint:
Blunt abdominal trauma is a known precipitating factor.
C
Hiccupping
Hint:
Hiccupping is a known precipitating factor.
D
Retching
Hint:
Retching is a known precipitating factor.
Question 5 Explanation: 
Although a Mallory-Weiss tear is often associated with alcohol use, it should be considered in all cases of upper GI bleed. Sneezing is not a known precipitating factor for Mallory-Weiss tear.
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