What is Mallory-Weiss Syndrome?
Mallory-Weiss syndrome (MWS) is a common reason for sudden bleeding in the upper part of your digestive system, also known as the gastrointestinal (GI) track. This condition involves superficial tears, or small cuts, in the lining of your digestive tract (known as mucosal lacerations). These tears mainly occur at the point where your stomach and esophagus meet, called the gastroesophageal junction. Sometimes these tears may spread up to the lower or middle part of the esophagus or even down to the upper part of the stomach.
A doctor named Albers first mentioned this condition in 1833, referring to it as ulcers at the lower part of the esophagus. However, the condition was more accurately described as tears, not ulcers, in 1929 by two doctors named Kenneth Mallory and Soma Weiss. They found that this condition often happened to individuals who had episodes of extremely forceful retching and vomiting, typically after drinking excessive amounts of alcohol.
Doctors usually diagnose MWS by using a procedure called endoscopy. This involves inserting a flexible tube with a camera down your throat to view your digestive tract. They look for a split or tear in the lining of the digestive tract near the gastroesophageal junction. The typical tear is about 2-4 cm long and most patients only have one tear. This tear is usually just below the junction on the lesser curve, or the smaller bend of the stomach.
What Causes Mallory-Weiss Syndrome?
Drinking a lot of alcohol is thought to be a major risk factor for Mallory-Weiss syndrome, as about 50% to 70% of patients diagnosed with this syndrome have a history of heavy drinking. The bleeding in the upper part of the stomach and esophagus that happens with Mallory-Weiss syndrome can be worse if patients also have high blood pressure in the portal vein (the large vein that brings blood to the liver) and esophageal varices (abnormally large veins in the tube that connects your throat and stomach).
The correlation between a hiatal hernia (when part of an organ, usually the stomach, pushes upward through the opening in the diaphragm) and Mallory-Weiss syndrome is still discussed by researchers. A hiatal hernia was seen in a good amount of cases with Mallory-Weiss syndrome, but a research study conducted at the Mayo Clinic in Florida found no differences in the number of hiatal hernias between patients with Mallory-Weiss syndrome and patients without it.
Certain conditions like bulimia nervosa, a condition causing excessive vomiting during pregnancy, and a condition causing acid reflux have also been linked to Mallory-Weiss syndrome. Each of these conditions can lead to stomach content being pushed back into the esophagus. Still, in a good number of patients (around 25% of cases), neither heavy drinking nor those conditions were present.
Mallory-Weiss syndrome can also occur after frequently straining or applying sudden pressure in the stomach like while vomiting, coughing, rescuing a person by manual cardiopulmonary resuscitation (CPR), or after sharp stomach injuries.
It’s rare for Mallory-Weiss syndrome to happen because of medical interventions. However, it may occur as a side effect of invasive tests like an upper gastrointestinal endoscopy (a procedure that allows your doctor to look at the interior lining of your esophagus and stomach) or trans-esophageal echocardiography (an ultrasound test that takes pictures of your heart). But, these procedures themselves have a very low risk (only about 0.07% to 0.49%) of causing Mallory-Weiss syndrome, so the risk is low.
Risk Factors and Frequency for Mallory-Weiss Syndrome
Mallory-Weiss syndrome (MWS) is responsible for 1% to 15% of upper gastrointestinal (GI) bleeding cases in adults, and less than 5% in children in the United States. This condition most commonly affects individuals between the ages of 40 and 60. While we don’t fully understand why, men are 2 to 4 times more likely to develop MWS than women. For younger women, a common cause of MWS is excessive vomiting, which can often occur during pregnancy, so pregnancy tests should be considered in these cases.
- Mallory-Weiss Syndrome (MWS) causes between 1% to 15% of upper GI bleeding in adults, and less than 5% in children in the U.S.
- The highest incidence of MWS occurs in people aged between 40 and 60.
- Men are 2 to 4 times more likely to develop MWS than women, and we’re not sure why.
- Excessive vomiting, which can happen during pregnancy, is a frequent cause of MWS in young women.
- Young women presenting with MWS should consider a pregnancy test.
Signs and Symptoms of Mallory-Weiss Syndrome
Mallory-Weiss syndrome is a condition that may not show any symptoms in mild cases. However, in about 85% of cases, the first symptom is hematemesis, which means vomiting blood. The amount of blood can vary greatly, from just a streak of blood mixed with mucus to severe and bright red bleeding.
If the bleeding is severe, other symptoms can appear. These can include melena (black, tarry stools), dizziness, fainting, or sharp pain in the upper middle part of the abdomen. This pain often indicates that there is an underlying condition present, such as gastroesophageal reflux disease (GERD), which is a chronic form of acid reflux.
In a physical examination, there are no signs that are specific only to Mallory-Weiss syndrome, as they echo those of other conditions that involve bleeding or shock. Some of the signs that a healthcare provider will look for include:
- A heart rate that’s faster than normal (tachycardia)
- A weak or thin pulse (thready pulse)
- Lower than normal blood pressure (hypotension)
- Signs of dehydration
- Decreased skin elasticity (reduced skin turgor)
- Slow refill of blood to the capillaries in the skin (capillary filling time)
If any of these signs are present, immediate medical intervention is necessary. Moreover, during a rectal examination, a doctor might find that the stool is black and tarry, which is a sign of blood in the stool (melena).
Testing for Mallory-Weiss Syndrome
When a patient comes to the hospital with hematemesis (vomiting blood), they need immediate care. The doctors will firstly need to understand the patient’s medical history and conduct a physical examination. Following this, the patient’s critical condition will be assessed, focusing on how severe the bleeding is. Sometimes, this bleeding can be quite heavy and taking internal damage into consideration, it becomes important to look for signs of shock, a condition where the body isn’t getting enough blood flow.
The clinicians will also request several blood tests. These include a complete blood count (CBC) which measures different components of the blood; tests for hemoglobin, which carries oxygen, and hematocrit, the portion of your blood that contains red blood cells. The coagulation profile, which involves tests to check your blood’s ability to clot, is also crucial. This includes tests for prothrombin time, partial thromboplastin time, and platelet count. For those suffering from chronic alcoholism, they might have a lower platelet count thus further increasing the risk of bleeding.
Aside from these, they will test kidney functions by evaluating blood urea nitrogen (BUN) and creatinine, helping identify any kidney failure. Any renal (kidney) failure is typically due to a condition called pre-renal azotemia, which occurs when decreased blood flow to the kidneys causes damage, unless the patient already has chronic kidney disease. In order to rule out heart problems which could also lead to chest pain and discomfort, they will measure cardiac enzymes and carry out an electrocardiogram (ECG).
The most effective way to clearly confirm a condition called Mallory Weiss tears, which are small tears in the lining of the esophagus that can cause bleeding, is through an upper gastrointestinal (GI) endoscopy. During an upper GI endoscopy, a thin tube with a light and camera is sent down your throat into your upper digestive system. This procedure not only helps doctors to visibly see the potential bleeding, clot, or crust over the tear but also helps in managing the bleeding. Usually, a single linear tear found just below the upper opening of the stomach verifies this diagnosis. The same procedure can also help in identifying other sources of bleeding, like swollen veins in the esophagus (esophageal varices) or stomach or duodenal ulcers. Typically, Mallory Weiss tears are about an inch long.
It’s recommended to avoid barium studies, which involve swallowing a barium solution to help with imaging, since they offer little diagnostic help and might interfere with the endoscopic diagnosis.
If there’s active bleeding from the tears that couldn’t be located or stopped using endoscopy, angiography might be recommended. Angiography is an imaging test that uses X-rays to view your body’s blood vessels.
Treatment Options for Mallory-Weiss Syndrome
Mallory-Weiss syndrome usually resolves on its own and it’s rare for it to come back. So, the first goal is to help stabilize the patient’s overall health. For most patients, a non-aggressive approach will be the best plan of action.
Right from the time of admission, appropriate measures should be initiated for patients with active bleeding. Evaluating and ensuring the patient’s airway, breathing, and circulation (commonly known as the ABC protocol) is essential in assessing how stable the patient is. To replace lost fluids and potentially save the life of a severely bleeding patient, a good IV (intravenous) line is set up and fluids are administered. If a patient’s hemoglobin level falls below 8 gm/dl, or if there are signs of severe bleeding or shock, an infusion of red blood cells may be required.
To relieve pressure in the stomach and help reduce the risk of additional bleeding, especially in patients who may also have swollen blood vessels in the esophagus, a nasogastric tube may be used for decompression. If there are any imbalances in the level of salts and minerals in the blood, these should be corrected. Before conducting any endoscopic examinations, blood clotting factors need to be optimized. Patients are usually sent home once the bleeding has stopped and all symptoms have been resolved.
Medication to reduce the amount of stomach acid is often given out. These include proton pump inhibitors (PPIs) and H2 blockers. Since an increase in stomach acid can slow down the healing of the stomach and esophagus lining, these medications can be very helpful. To suppress nausea and vomiting, anti-nausea drugs such as promethazine and ondansetron may be used.
One way to diagnose and potentially treat upper GI (gastrointestinal) bleeding is through an examination called an esophagogastroscopy. If bleeding has already stopped by the time of this examination, no further treatment might be necessary. If bleeding is still active or recurrent, methods such as injecting a diluted epinephrine to cause vasoconstriction (narrowing of the blood vessels), multi-polar electrocoagulation, injecting a sclerosant agent, Argon plasma coagulation, or endoscopic band ligation can be used.
If an endoscopy isn’t possible or hasn’t solved the issue, angiography can be considered. This is a type of x-ray used to visualize the inside of the blood vessels. This could involve an injection of a drug to constrict the blood vessels or a procedure to block the blood flow to the left gastric or superior mesenteric artery.
Surgery is rarely necessary and is usually only considered if all other options have failed. This might involve a procedure to stitch up the tear using a laparoscope (a long thin telescope with a light and camera at the end) guided by an endoscope.
The Sengstaken-Blakemore tube is a device used to stop bleeding, but this is usually the last treatment option used. It’s only typically used in patients with significant other health issues and it’s not a preferred option. This is because the bleeding is usually due to an artery and this treatment doesn’t provide enough pressure to stop the arterial bleeding.
What else can Mallory-Weiss Syndrome be?
When trying to diagnose Mallory-Weiss syndrome, which can cause bleeding in the upper part of your digestive system, doctors need to make sure it’s not one of a number of other conditions that can cause similar symptoms. These may include:
- Boerhaave syndrome: This is a severe condition that has the same risk factors as Mallory-Weiss syndrome, but it involves a tear in the esophagus.
- Peptic ulcer: This is the most common cause of upper digestive system bleeding, and it can typically be accurately diagnosed with a procedure called an endoscopy.
- Esophageal or stomach cancers
- Esophageal varices: These are enlarged, twisted blood vessels around the lower part of the esophagus. These often happen as a result of high blood pressure in the veins that go to your liver. But it’s also possible for someone to have both esophageal varices and Mallory-Weiss syndrome at the same time.
- Arteriovenous malformations: These are defects in your circulatory system that are typically present at birth.
What to expect with Mallory-Weiss Syndrome
For most patients, the results are typically positive. Bleeding usually stops on its own in the majority of cases, and the tear generally heals within a 72-hour period. Though the amount of blood lost can differ, it’s not often that a blood transfusion is needed.
Possible Complications When Diagnosed with Mallory-Weiss Syndrome
The difficulties that arise from this condition are connected to how much blood is lost. This can lead to a severe drop in blood pressure, imbalances in your body’s chemistry, and even heart attacks. If the bleeding isn’t stopped, it can be fatal. Cases of a ruptured esophagus and a return of Mallory Weiss syndrome are uncommon.
Common issues include:
- Severe drop in blood pressure
- Imbalances in body’s chemistry
- Heart attacks
- Potential death due to uncontrolled bleeding
- Ruptured esophagus
- Return of Mallory Weiss syndrome
Preventing Mallory-Weiss Syndrome
While the condition isn’t very widespread, it’s important for patients to know the dangers of drinking too much alcohol, which can cause a health issue known as Mallory Weiss tears. Mallory Weiss tears are small tears in the lining of your esophagus – the tube that connects your throat to your stomach – that can happen when you drink excessively.
It’s crucial to advise patients who have previously had episodes of vomiting blood (hematemesis) to steer clear of triggers that can lead to these tears in the esophagus. This precaution remains important even though it’s rare for the condition to happen again.
