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Clinical Column
Clinical Column

Overview of Mallory-Weiss syndrome

Kathleen Rich, PhD, RN, CCNS, CCRN-CSC, CNN

syndrome Kathleen Rich, PhD, RN, CCNS, CCRN-CSC, CNN Mallory-Weiss syndrome (MWS), also known as Mallory- Weiss

Mallory-Weiss syndrome (MWS), also known as Mallory- Weiss tear(s), is defined as longitudinal, nonperforating mucosal lacerations in the gastroesophageal junction resulting in upper gastrointestinal (GI) bleeding. 1 It is estimated that WMS is the cause of 8%–15% of nonvariceal upper GI bleeding. 2 This col- umn will provide an overview of MWS including demographics, pathogenesis, associated risk factors, presenting symptoms, treat- ment, and nursing considerations.

DEMOGRAPHICS

MWS was first described in 1929 by Mallory and Weiss 3 in patients experiencing vomiting after binging on alcohol. Although MWS has been reported in all age groups, the majority of patients are in their 40s–50s. Males have a higher incidence than females with a ratio of 2:1–4:1. 2 A study by Ljubicic et al 4 revealed a one-year cumulative incidence for MWS bleeding of 7.3 cases/100,000 persons and an overall 30-day mortality rate of 5.3%. Pabst et al examined the cause and fre- quency of upper GI bleeding after infrarenal aortic graft surgery, with MWS being reported as the cause in 1 out of 74 postopera- tive bleeding episodes. 5

PATHOGENESIS AND RISK FACTORS

Although not completely understood, it is proposed that the primary mechanism behind the mucosal lacerations is a sudden, significant increase in intragastric and intraabdominal pressure that is transmitted to the gastroesophageal junction and esophagus. 2,6 Risk factors include retching, vomiting, hiccups, blunt abdominal trauma, chest trauma (including cardiopulmonary resuscitation), coughing, primal scream therapy, and seizures. 2,6 Alcohol use is reported in 30%–60%

From the Franciscan Health – Michigan City, Michigan City, Indiana.

Corresponding author: Kathleen Rich, PhD, RN, CCNS, CCRN- CSC, CNN, Critical Care Clinical Nurse Specialist, Franciscan Health – Michigan City, 301 W. Homer Street, Michigan City, IN 46360 (E-mail: Kathleen.rich@franciscanalliance.org ).

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Copyright 2018 by the Society for Vascular Nursing, Inc.

of patients. 2 Iatrogenic causes such as trauma from insertion or manipulation of a transesophageal echocardiogram probe have been associated with MWS. 7,8 The presence of a hiatal hernia has been documented as a predisposing factor because it is present in 40%–80% of MWS patients. 2,6 During vomiting, the transmural pressure gradient is thought to be greater in the hiatal hernia than that in rest of the stomach, causing the lacerations. However, an age- and gender-matched study from a national database report of MWS patients found no significant difference in the hiatal hernia incidence between the two groups. 9 Table 1 summarizes the common risk factors of MWS.

SYMPTOMS AND DIAGNOSIS

An acute onset of hematemesis, that is, either frank red blood or coffee ground in appearance, is present in the majority of patients. 6,10 This upper GI bleeding is often preceded by an episode of vomiting, retching, straining, or coughing. 2,6 Additional symptoms include back or epigastric pain, melena, or hematochezia. Signs of shock such as hypotension and tachycardia may be present depending on the blood loss volume. 2,6,7 Obtaining a medical history to identify for the presence of risk factors, medication use, and comorbid conditions assists in differentiating potential bleeding causes. 10 Baseline laboratory tests include a complete blood count, serum electrolytes, blood urea nitrogen, creatinine liver function, and coagulation tests to assess the patient’s current status. 2,6,10 Additional diagnostics may be ordered based on the admitting presentation and medical history. An esophagogastroduodenoscopy is considered the gold standard to obtain an accurate diagnosis. 2,6,10,11 Figure 1 depicts the endoscopic appearance of a Mallory-Weiss tear. Use of a risk stratification scale such as the Rockall scoring system aids the physician in identifying those patients at risk for adverse out- comes of rebleeding or death. 6,12

TREATMENT

The initial management of any patient with upper GI bleeding includes assessing for hemodynamic instability, subsequent pa- tient stabilization with intravenous (IV) fluid resuscitation, and, if indicated, blood product transfusions. 2,6,10 The patient is kept NPO (nothing by mouth) until bleeding is controlled, and the endoscopic evaluation is done. Medications that potentiate bleeding are held. Insertion of a nasogastric tube may be

TABLE 1

RISK FACTORS FOR MALLORY-WEISS SYNDROME

Retching and vomiting Hiccups Coughing Primal scream therapy Chest wall trauma (including cardiopulmonary resuscitation) Blunt abdominal trauma Seizures Iatrogenic (e.g. transesophageal echocardiogram) Pre-existing hiatal hernia

ordered. Serial monitoring of the hemoglobin and hematocrit is done. In the majority of patients, bleeding resolves spontaneously. 2,6,11 If indicated, endoscopic treatment options include one or more of the following: injection therapy (typically with epinephrine), electrocoagulation, hemoclip, or band ligation. 2,6,11 If the endoscopic treatment is unsuccessful, angiographic transarterial embolization may be performed. 6,13 A laparotomy to oversee the bleeding vessel is often reserved for uncontrolled or repeated bleeding or failure of the angiographic intervention. 2,6 Recurrent bleeding is more commonly seen in patients presenting with signs of shock on arrival to the hospital, a low initial hematocrit, or those with active bleeding upon endoscopy. 6,11 Secondary use of an IV proton pump inhibitor for acid suppression is prescribed either twice daily or by continuous infusion depending on the severity of bleeding and physician preference. A proton pump inhibitor is felt to promote hemostasis and clot stability by raising the intragastric pH. 10,14 Administration of an IV

intragastric pH. 1 0 , 1 4 Administration of an IV Figure 1. Endoscopic appearance of

Figure 1. Endoscopic appearance of Mallory-Weiss tear with mild oozing. The tear starts at the gastroesophageal junction (large ar- row) and extends distally into the hiatal hernia (small arrow). FIG. 28.5. From Feldman M, et al. Sleisenger and Fordtran’s Gastro- intestinal and Liver Disease. 10th Ed. Philadelphia: Elsevier; 2016.

antiemetic such as ondansetron is ordered in persistent nausea and vomiting conditions. 6

NURSING CONSIDERATIONS

Frequent monitoring of the vital signs and clinical assessments for signs of hemodynamic instability and continued bleeding are standard. Prompt physician notification of abnormal laboratory values or changes in the patient’s condition will assist in timely administration of IV fluids, medications, and blood products. If the physician has ordered a nasogastric tube before the esophagogastroduodenoscopy, insert the tube and perform gastric lavage to cleanse the stomach. 10 Assess for potential comorbid condition involvement resulting from blood loss, such as the development of angina due to a low hemoglobin level. 10 Provide patient education including risk factor modification and counseling referral if there is a history of alcohol abuse. Incorporate these interventions into the nursing plan of care. In patients with continual nau sea and vomiting, a sched- uled rather than PRN (as necess ary) antiemetic administration may be considered. In the hos pitalized patient requiring a surgical procedure, the nurse should be aware of the risk of MWS developing from postoperative nausea and vom iting (PONV). 15 PONV is defined as any nausea, retching, or vomiting occurring during the first 24–48 hours after surgery. 16 The reported incidence of PONV is 30% in all postsurgical patients. 15,16 Risk factors include female gender, nonsmoker, history of PONV or motion sickness, general anesthesia technique, anesthesia duration, and use of volatile anesthetics and opioids. 15,16 The three classes of antiemetic drugs, such as serotonin antagonists (eg, ondansetron), corticosteroids (eg, dexamethasone), and dopamine antagonists (eg, droperidol), have a similar efficacy in treating PONV. 16 The nurse should be knowledge- able of potential antiemetic sid e effects. Vomit is inspected for signs of blood, and if presen t, the physician is notified. A postoperative pain control plan that includes nonsteroidal anti-inflammatory drugs and other non-opioids to reduce opioid use will assist in reducing the incidence of PONV. 15,16 MWS is a relatively common cause of nonvariceal upper GI bleeding that occurs in both the community and hospital settings. The bleeding continuum ranges from spontaneous bleeding cessation to life-threatening hemorrhage. Hospitalized vascular patients are at risk for MWS development due to the presence of underlying risk factors or development of PONV after a surgi- cal intervention and/or opioid administration. Nursing knowl- edge of the risk factors, symptoms, diagnosis, and treatment options will improve the care delivered and assist in preventing any adverse outcomes.

REFERENCES

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6. Guelrud M. Mallory-weiss syndrome. Up to Date, Inc. Wol- ters Kluwer; 2017; https://www.uptodate.com/contents/ma llory-weiss-syndrome . Accessed February 25, 2018.

15. Feinleib J, Kwan L, Yamani A. Postoperative nausea and vomiting. Up to Date, Inc. Wolters Kluwer; 2017; https:// www.uptodate.com/contents/postoperative-nausea-and-vom iting . Accessed March 14, 2018.