Mallory-Weiss tear

Linear mucosal or submucosal lacerations at or near GOJ resulting from forceful retching/vomiting that may lead to UGIB.

• Initially described by Kenneth Mallory and Soma Weiss in 1929

Pathophysiology

• Results from large gradient in pressure between stomach and thorax, which occurs at GOJ
• Can result from 'any action which results in an abrupt increase in intra-abdominal pressure and gastric herniation'
  • Vomiting
  • Coughing
  • Straining
• Most tears occur below GOJ (within 2cm), and along lesser curve

Risk factors

• Hiatus hernia (found in 50% of cases)
• 40-60 year old patients
• Aspirin/alcohol can make bleeding worse

Risks for worse outcomes

• Older
• Anaemia
• Shock at presentation
• Active bleeding on endoscopy
• Alcoholic patients with portal hypertension

Presentation

• Non-bloody vomiting followed by haematemesis is classic
• Seen in 5-15% of patients with UGIB (behind only PUD in non-variceal UGIB)
• MOSTLY self-limiting

Treatment approach

• Generally identified during initial endoscopy for UGIB - treat with adrenaline and gold probe, or haemoclip if gold probe is unavailable
• If patient becomes unstable again, or there is large bleeding and you are unable to get control endoscopically, consider transarterial embolisation if available
• If all else fails, operate

Management options

• Medical
  • PPI (raises gastric pH to improve coagulation)
  • Anti-emetic
• Endoscopic intervention if active bleeding
  • 90-100% success rate
  • Injection therapy
    • Adrenaline 1-3mL of 1:10,000
      • Mix 1mL of 1:1000 adrenaline with 9mL saline
      • Great outcomes but combine with second therapy
    • Sclerosing agents
  • Multipolar electrocoagulation
  • Band ligation
  • Haemoclipping
• Interventional embolotherapy
• Surgery
  • Very rarely indicated
  • High anterior longitudinal gastrotomy to visualise GOJ mucosa
  • Oversew with 2/0 Vicryl to reappose mucosa