Mallory Weiss Tear
Endoscopy of Mallory Weiss Tear

Video Endoscopic Sequence 1 of 8.

Endoscopy of Mallory Weiss Tear

This 38 year-old male, who had been drinking an average of 20 beers a day for a week, experienced severe hematemesis after about an hour of intense vomiting. He was hospitalized for stabilization and underwent endoscopy showing active bleeding from a gastroesophageal tear.

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Mallory-Weiss tear

Video Endoscopic Sequence 2 of 8.

Endoscopy of Mallory Weiss Tear

The gastroesophageal junction shows a blood clot that covers one of the tears. It is an exact site of bleeding shown in the video clips and shows active bleeding represented by the fresh red blood.

The original description by Mallory and Weiss in 1929 involved patients with persistent retching and vomiting following an alcoholic binge. However, Mallory-Weiss syndrome may occur after any event that provokes a sudden rise in intragastric pressure or gastric prolapse into the esophagus.



Mallory-Weiss tear

Video Endoscopic Sequence 3 of 8.

Endoscopy of Mallory Weiss Tear

At the cardias there are multiple tears

The image seen in retroflexion shows multiple lacerations with bleeding, the exact site of the bleeding is the tear covering the clot.

Precipitating factors include retching, vomiting, straining, hiccupping, coughing, primal scream therapy, blunt abdominal trauma, and cardiopulmonary resuscitation. In a few cases, no apparent precipitating factor can be identified. One study reported that 25% of patients had no identifiable risk factor.

The presence of a hiatal hernia is a predisposing factor and is found in 35-100% of patients with Mallory-Weiss tears. During retching or vomiting, the transmural pressure gradient is greater within the hernia than the rest of the stomach, and it is the location most likely to sustain a tear (see Potential Mechanisms for Mallory-Weiss Tears).

Mallory-Weiss tears are usually associated with other mucosal lesions. In one study, 83% of patients had additional mucosal abnormalities potentially contributing to bleeding or actually causing retching and vomiting that would induce these tears.

Iatrogenic tears are uncommon, considering the frequency with which patients retch during endoscopy. The reported prevalence is 0.07-0.49%.


Mallory-Weiss tear

Video Endoscopic Sequence 4 of 8.

Endoscopy of Mallory Weiss Tear

Because the patient presented with hematemesis during the endoscopy as an outpatient, we decided to perform a second endoscopy in the operating room to attempt therapeutic hemostasis while minimizing the potential of bronchoaspiration. The second endoscopy was after several hours, thus the bleeding was not as active and we decided not to use endotracheal intubation.


Mallory-Weiss tear

Video Endoscopic Sequence 5 of 8.

Endoscopy of Mallory Weiss Tear

For the hemostasis of small tears, argon plasma coagulator was used with excellent results.

A Mallory-Weiss tear likely occurs as a result of a large, rapidly occurring, and transient transmural pressure gradient across the region of the gastroesophageal junction. Acute distention of the nondistensible lower esophagus can also produce a linear tear in this region.

With a rapid rise in intragastric pressure due to precipitating factors, such as retching or vomiting, the transmural pressure gradient increases dramatically across the hiatal hernia, which abuts a low intrathoracic pressure zone. If the shearing forces are high enough, a longitudinal laceration eventually occurs. Within the hernia, the tear is more likely to involve the lesser curvature of the gastric cardia, which is relatively immobile compared to the remainder of the stomach.

Another potential mechanism for Mallory-Weiss tears is the violent prolapse or intussusception of the upper stomach into the esophagus, as can be witnessed during forceful retching at endoscopy.




Mallory-Weiss tear

Video Endoscopic Sequence 6 of 8.

Endoscopy of Mallory Weiss Tear.

Status post argon plasma coagulation.

Several endoscopic modalities are effective for treating a bleeding Mallory-Weiss tear. The choice usually depends on the endoscopist's familiarity with a particular technique and on equipment availability.

To treat or not to treat
Most patients have stopped bleeding at the time of endoscopy. Patients with actively bleeding Mallory-Weiss tears (ie, arterial spurting, streaming from focal point, diffuse oozing) are treated. Stigmata (eg, nonbleeding visible vessel, adherent clot) do not necessarily require treatment in Mallory-Weiss tears as they do in peptic ulcers. Such stigmata are usually not treated unless they are rebleeding episodes from the same lesion or are associated with a coagulopathy. Tears with a clean, fibrinous base or with flat, pigmented spots are not treated, as the risk of rebleeding is minimal.


 

 

Mallory-Weiss tear

Video Endoscopic Sequence 7 of 8.

Endoscopy of Mallory Weiss Tear.

In order to perform hemostasis of the active bleeding, which originated beneath the clot, we shot three rubber bands using the band ligation device.

Band ligation
Endoscopic band ligation has been shown to be effective for treating bleeding Mallory-Weiss tears.

Band ligation should be particularly useful for bleeding Mallory-Weiss tears associated with portal hypertension and gastroesophageal varices, in which thermal therapy is not recommended.


Mallory-Weiss tear

Video Endoscopic Sequence 8 of 8.

Endoscopy of Mallory Weiss Tear.

Final status of the hemostatic treatment.

The Complete hemostasis is obtained using both techniques the argon plasma and the rubber band, the patient was discharged the next day.

The prognosis of Mallory-Weiss tears is generally good. Bleeding from these lesions stops spontaneously in 80-90% of patients. With conservative therapy, most tears heal uneventfully within 48-72 hours. Thus, a Mallory-Weiss tear can easily be missed if endoscopy is delayed.

The degree of blood loss varies. Earlier studies reported that the proportion of patients requiring blood transfusions was 40-70%. Currently, these figures are probably significantly lower.

Hemodynamic instability and shock may occur in up to 10% of patients with Mallory-Weiss tears. In one series, mortality as high as 8.6% was attributed to these lesions; however, current clinical experience suggests a significantly lower mortality rate from Mallory-Weiss tears.

Recurrence of these lesions is rare. However, counsel patients who have had a Mallory-Weiss tear on precipitating factors (eg, alcoholic binge, excessive straining and lifting, violent coughing) that may lead to a recurrent lesion (see Risk Factors for Mallory-Weiss Tears).

 



Mallory-Weiss tear

Video Endoscopic Sequence 1 of 2.

Endoscopy of Mallory Weiss Tear.

This 58 year-old female, 3 days previously had hematemesis.


Mallory-Weiss tear

Video Endoscopic Sequence 2 of 2.

A Hiatal Hernia is seen with longitudinal tear.

Hiatal hernia has been found in 40 to 100 percent of patients with Mallory-Weiss tears and has been considered by some to be a necessary predisposing factor. It has been proposed that, in hiatus hernia, a higher pressure gradient develops in the hernia compared with that in the rest of the stomach during retching, thereby increasing the potential for mucosal laceration. Gastroesophageal tears may also be more likely to occur when the upper esophageal sphincter does not relax during vomiting.

Mallory-Weiss syndrome is characterized by longitudinal mucosal lacerations (intramural dissections) in the distal esophagus and proximal stomach, which are usually associated with forceful retching. The lacerations often lead to bleeding from submucosal arteries. Since the initial description in 1929 by Mallory and Weiss in 15 alcoholic subjects.



Mallory-Weiss tear

Video Endoscopic Sequence 1 of 3.

Endoscopy of Mallory Weiss Syndrome

A Mallory–Weiss tear located at the gastroesophageal
junction with an

This 42 year-old male, two days previously has been drinking alcoholic beverages, started vomiting, immediately patient initiates with hematemesis follow with melena.

The image displays a blood clot that covers the mucosal tear.

The classic presentation consists of an episode of hematemesis following a bout of retching or vomiting, although this presentation may be less common than previously thought.



Mallory-Weiss tear

Video Endoscopic Sequence 2 of 3.

Retroflexed image
Pathophysiology

A Mallory-Weiss tear (MWT) likely occurs as a result of a large, rapidly occurring, and transient transmural pressure gradient across the region of the gastroesophageal junction. Acute distension of the nondistensible lower esophagus can also produce a linear tear in this region.

With a rapid rise in intragastric pressure due to precipitating factors, such as retching or vomiting, the transmural pressure gradient increases dramatically across the hiatal hernia, which abuts a low intrathoracic pressure zone. If the shearing forces are high enough, a longitudinal laceration eventually occurs. Within the hernia, the tear is more likely to involve the lesser curvature of the gastric cardia, which is relatively immobile compared to the remainder of the stomach.

Another potential mechanism for MWTs is the violent prolapse or intussusception of the upper stomach into the esophagus, as can be witnessed during forceful retching at endoscopy.


Mallory-Weiss tear

Video Endoscopic Sequence 3 of 3.

The Hiatus Hernia displays the blood clot.

Bleeding from MWTs stops spontaneously in 80-90% of patients. With conservative therapy, most tears heal uneventfully within 48 hours. Thus, a MWT can easily be missed if endoscopy is delayed.

The degree of blood loss varies. Earlier studies reported that the proportion of patients requiring blood transfusions was 40-70%. These figures do not seem to be the trend today and are probably significantly lower.

Hemodynamic instability and shock may occur in up to 10% of patients. In one series, mortality as high as 8.6% was attributed to MWTs. Current clinical experience suggests a significantly lower mortality rate from MWTs.

 

Mallory-Weiss tear

Video Endoscopic Sequence 1 of 3.

A 68 year-old female, one week previously presented a history of severe vomiting, which later had melena.

The endoscopy displayed here is performed one week after the inicial symtoms. A Mallory Weiss tear was showed, presented as a linear ulcer. The Mallory Weiss tear is localized to the gastric side side of the squamocolumnar junction or extends across the z line into the esophagus.

The original description by Mallory and Weiss in 1929 involvedpatients with persistent retching and vomiting following analcoholic binge. However, Mallory-Weiss syndrome may occurafter any event that provokes a sudden rise in intragastricpressure or gastric prolapse into the esophagus.Pathophysiology: A Mallory-Weiss tear (MWT) likely occursas a result of a large, rapidly occurring, and transient transmuralpressure gradient across the region of the gastroesophagealjunction. Acute distension of the nondistensible lower esophaguscan also produce a linear tear in this region.With a rapid rise in intragastric pressure due to precipitatingfactors such as retching or vomiting, the transmural pressuregradient increases dramatically across the hiatal hernia, whichabuts a low intrathoracic pressure zone. If the shearing forces arehigh enough, a longitudinal laceration eventually occurs. Within thehernia, the tear is more likely to involve the lesser curvature of thegastric cardia, which is relatively immobile compared to theremainder of the stomach.Another potential mechanism for MWTs is the violent prolapse orintussusception of the upper stomach into the esophagus, as canbe witnessed during forceful retching at endoscopy.

 

Mallory-Weiss tear

Video Endoscopic Sequence 2 of 3.

Same case as above, the retroflexed maneuver displays
a linear ulcer at the gastroesophageal junction.

The Mallory Weiss tear is an acute lesion that, when
viewed soon after the tear occurs, has the appearance of
an edematous and irregular split in the mucosa. 
Bleeding is usually multifocal, but can arise from an
exposed intramural artery branching off the left gastric
artery.



Mallory-Weiss tear

Video Endoscopic Sequence 3 of 3.

The classic presentation for the Mallory Weiss tear is
a sequence of events beginning with nausea and
vomiting followed soon by hematemesis.

Mallory-Weiss tear

A 43 year-old man who had been drinking alcoholic
beverages, after that, he undergone vomiting and bleeding.
The video clip displays a hiatal hernia, reflux esophagitis
and a blood clot that covers the mucosal tear.

A history of heavy alcohol use leading to vomiting has been
noted in 40 to 80 percent of patients with Mallory-Weiss
syndrome in most series. The bleeding is usually more
severe when Mallory-Weiss tears are associated with
portal hypertension and esophageal varices. Occasionally,
patients give a history of ingestion of aspirin or
nonsteroidal antiinflammatory drug.

 

Mallory-Weiss tear

Mallory Weiss Syndrome.

34 year-old male physician who had been drinking alcoholic
beverages and started vomiting, immediately, after that,
the patient had an upper gastrointestinal bleeding.

Mallory-Weiss tear

Video Endoscopic Sequence 1 of 3.

54 year-old female, who had induced vomiting a day before
because of a feeling of malaise. Melena was observed.
Her hemoglobin was 8.1 mg/dl.
She underwent upper endoscopy, and a gastroesophageal
tear was found at the gastroesophagic junction.

Mallory-Weiss tear

Video Endoscopic Sequence 2 of 3.

The image and the video display a ulcer with a blood clot
the endoscope is retroflexed.

Mallory-Weiss tear

Video Endoscopic Sequence 3 of 3.

The blood clot is observed in retroflexed maneuver.

How frequently a Mallory-Weiss tear occurs without
bleeding cannot be determined with any certainty. It is
highly likely that the condition occurs in a less severe form
more frequently than is recognized.

 

Mallory-Weiss tear

Mallory-Weiss tears occurring during endoscopy

Mallory-Weiss tears occurring during the course of upper
gastrointestinal endoscopy are apparently rare, Iatrogenic
Mallory-Weiss tears are rare and generally have a benign
course. They tend to occur mostly in patients who have
experienced excessive retching or struggling during
endoscopy. Mallory-Weiss tears complicating endoscopy
occur especially in elderly, female patients with hiatal
hernias. The importance of admitting patients with this
complication to hospital for overnight observation is
recommended in view of the possible development of
haemorrhage or perforation.


 

Pubmed

   

Mallory-Weiss tear

Video Endoscopic Sequence 1 of 9.

Mallory-Weiss Syndrome

This 54 year-old female, had some episodes of vomiting
presented with hematemesis, she was diagnostic as having
Mallory Weiss tear, after that the patient presented
intermittent melena during a one week, She was referred
to our endoscopic unit for evaluation.

 

Mallory-Weiss tear

Video Endoscopic Sequence 2 of 9.

An adhered blood clot is observed of where it is the exact site of bleeding.

Mallory-Weiss tear

Video Endoscopic Sequence 3 of 9.

At the gastric fundus, there are rest of dark blood.







Mallory-Weiss tear

Video Endoscopic Sequence 4 of 9.

There is a slight bleeding around of the blood clot .

Mallory-Weiss tear

Video Endoscopic Sequence 5 of 9.

Overlying clot seen in close-up view.

Mallory-Weiss tear

Video Endoscopic Sequence 6 of 9.

Immediately above of the blood clot there is an erosion in phase of healing.

Mallory-Weiss tear

Video Endoscopic Sequence 7 of 9.

Mallory-Weiss tear

 

 

 

Mallory-Weiss tear

Video Endoscopic Sequence 8 of 9.

The hemostatic therapy with argon plasma has been initiated.


Mallory-Weiss tear

Video Endoscopic Sequence 9 of 9.

The hemostatic treatment was carried out ambulatorily, the
patient was handled with proton pump inhibitors evolving
without newness.

Mallory-Weiss tear

Video Endoscopic Sequence 1 of 2.

Mallory Weiss Tear and Gastric Cancer

This is a 82 year-old male, an upper endoscopy was practiced because of  weight loss more than 20 pounds, anorexia and vomiting.

At Endoscopy an ulcerated gastric cancer of the antrum with retained food and liquid in the gastric foundus was found.

During this procedure started vomiting of food content, immediately the endoscope was withdrawn.

 


Mallory-Weiss tear

Video Endoscopic Sequence 2 of 2.

Mallory-Weiss tear during endoscopy in a patien with gastric cancer

Having stabilized the patient, again proceeds to perform endoscopy, tearing is observing in the gastroesophageal junction. 

Mallory-Weiss tear

Video Endoscopic Sequence 1 of 4.

Endoscopy of Mallory Weiss tear and Duodenal ulcer.

This is a 68 year-old, male, who iniciated with hematemesis and melena. A few days before this episode had had chikungunya disease.

At the outbreak of this virus in El Salvador, perhaps by use of analgesics have been several cases of bleeding of the digestive apparatus. But also to lower gastrointestinal tract

This disease was first presented in the Republic of El Salvador, appeared in the country, in late May 2014.

Chikungunya (pronunciation: \chik-en-gun-ye) virus is transmitted to people by mosquitoes. The most common symptoms of chikungunya virus infection are fever and joint pain. Other symptoms may include headache, muscle pain, joint swelling, or rash. Outbreaks have occurred in countries in Africa, Asia, Europe, and the Indian and Pacific Oceans. In late 2013, chikungunya virus was found for the first time in the Americas on islands in the Caribbean. There is a risk that the virus will be imported to new areas by infected travelers. There is no vaccine to prevent or medicine to treat chikungunya virus infection. Travelers can protect themselves by preventing mosquito bites. When traveling to countries with chikungunya virus, use insect repellent, wear long sleeves and pants, and stay in places with air conditioning or that use window and door screens.

Chikungunya fever first appeared in Tanzania in 1952 and from there migrated to the rest of Africa and Asia, according to the World Health Organization (WHO).

 

Mallory-Weiss tear

Video Endoscopic Sequence 2 of 4.

Endoscopy of Mallory Weiss tear and Duodenal ulcer.

An ulcer of the duodenal bulb with a clot, which is another site of bleeding.

 

 

Mallory-Weiss tear

Video Endoscopic Sequence 3 of 4.

Endoscopy of Mallory Weiss tear

Mallory-Weiss tear

Video Endoscopic Sequence 4 of 4.

For the hemostasis of the tears, argon plasma coagulator
was used

 

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