Mallory Weiss syndrome

Anatomy & Psychology1 4/30/19 Mallory-Weiss Syndrome Daniella Benjamin Mallory-Weiss tear is a laceration in the lining of the upper part of the gut, i.e. gastrointestinal tract. This part of the upper gut includes the gullet, i.e. esophagus, the stomach and the duodendum. Hence Mallory-Weiss Syndrome (MWS) is the condition marked by this tear in the inner lining, where the esophagus meets the stomach. MWS is characterized by longitudinal mucosal lacerations (intramural dissections) in the distal esophagus and proximal stomach; which are usually associated with forceful retching. The lacerations can often result in bleeding (GI) from the submucosal arteries. The initial description and discovery occurred in 1929 by Mallory and Weiss. The study involved 15 alcoholic subjects that experienced bleeding after binging on alcohol. The gastroesophageal tears have been recognized as the cause of upper gastro intestinal bleeding, i.e. hemorrhage. The prevalence of such tears among patients presented with upper gastrointestinal bleeding is approximately 5 percent. Perforation can occur with repeated, protracted vomiting or it could occur after one single incident. Essentially, there is no certainty to know how frequent a Mallory-Weiss tear occurs without bleeding. For instance in another given study, patients receiving colonoscopy preparation with polyethylene out of 1248 consecutive patients, a Mallory Weiss tear was found in 13 patients; following the gastroscopy by colonoscopy in some standard preparation of glycol electrolyte. More studies have shown this is more common with men than women.The Pathogenesis and Risk factors Although it is not completely understood, it is thought that the primary mechanism behind the lacerations is due to the sudden, significant increase in intragastric and intra-abdominal pressure that is passed to the gastroesophageal junction and esophagus. The main risk factors include retching, vomiting, hiccups, blunt abdominal trauma and chest trauma. This could also include cardiopulmonary resuscitation, coughing, primal scream therapy, and seizures. Alcohol use is reported in roughly 30%-60% of patients. Another risk factor includes hiatal hernia. Moreover, there have been reported cases of persons with Bulimia Nervosa – could potentially lead to MWS. In cases of vomiting, the transmural pressure is thought to be greater in the hiatal hernia than the rest of the stomach. This is known to cause the lacerations. Symptoms and Diagnosis Symptoms can include a small onset of hematemesis, that is, either red blood or coffee ground in appearance, in most of the patients. The upper GI bleeding is often preceded by an episode of vomiting, retching, straining, or coughing. Some other symptoms may include back or epigastric pain; melena, i.e. black tarry stool; or hematochezia, i.e. bleeding from the rectum or stool. One should obtain a patient history to find out the volume of blood loss, medications, risk factors, and potential risk factors to determine the underlying issue. There is a plethora of testing that can be ordered, such as a request of laboratory blood count; blood urea nitrogen; creatinine liver function; and/ or coagulation test. The highest standard would be esophagogastroduodenoscopy (EGD), which is a test to examine the lining of the esophagus, stomach and first part of the small intestine. The endoscope can help one see the longitudinal tears, even multiple ones. An EGD is an effective and more precise for diagnosis and/ or seeing the endoscopic tears. Something known as Rockall risk scoring system, which I am not too familiar with, but understand is a number score to assess the amount of GI bleeding. This score can later assist the physician in identifying those patients whom are at risk for adverse outcomes and/ or re-bleeding to death. Treatment PlanTo maintain proper care for a patient with upper GI bleeding, this would include assessing for hemodynamic instability; stabilizing the patient with IV fluid resuscitation; and if necessary protocol blood product type transfusions. Be advised that no medication should be given by mouth until the bleeding is fully controlled and the endoscopic test is evaluated – and is given the all clear. This precaution is necessary because some medications could cause further bleeding. In some instances, a nasogastric tube may be ordered. In many cases the bleeding corrects itself spontaneously. Other treatment that can be utilized, if needed, are injection therapy (eninerphine); electrocoagulation, i.e. using electrical current to stop the bleeding; hemoclip or band ligation. If endoscopic treatment is unsuccessful, then angiographic transarterial embolization may be performed. A laparotomy will oversee the blood vessels. Patients with shock have more uncontrolled bleeding. Depending on the severity of the bleeding, a pump inhibitor for acid suppression can be used once or twice daily. This is performed by an IV antiemetic such as ondansetron, this helps the patient deal with constant nausea. Interventional radiology should be used for unstable patients who re-bleed after endoscopic treatment. If there is still no resolution after another endoscopy – percutaneous angiography may be used to localize the bleeding point and embolization of the artery using foam and coils to stop bleeding. The benefits of embolization have to be balanced against the risk of causing ischemic necrosis of the gastrointestinal tract. Refer urgently for surgery if interventional radiology is not immediately available. I anticipate the reader was able to grasp a full understanding underlying medical issues of MWS and fully informed of the procedures taken to treat it. This paper was written to inform patients of the issues; but more so directed towards doctors or nurses caring for patients in this predicament. There are several organs in our abdominal regions and this is just one issue that could manifest. The vast complexity of the multitude of symptoms pertaining to the abdominal region makes it difficult to treat, and even more so to identify potential issues. That being said, I have a better indication of what is meant when it is said that our stomach is like our second brain – food for thought. ReferencesRarediseases.info.nih.gov. (2019). Mallory-Weiss syndrome | Genetic and Rare Diseases Information Center (GARD) – an NCATS Program. [online] Available at: https://rarediseases.info.nih.gov/diseases/6967/mallory-weiss-syndrome [Accessed 30 Apr. 2019].Evidence.nhs.uk. (2019). Mallory weiss syndrome | Evidence search | NICE. [online] Available at: https://www.evidence.nhs.uk/search?q=Mallory+weiss+syndrome [Accessed 30 Apr. 2019]. Symptoms and Causes of Mallory-Weiss Syndrome. (2018, May 24). Retrieved from https://facty.com/ailments/stomach/symptoms-and-causes-of-mallory-weiss-syndrome/?style=quick&utm_source=bing-up&utm_medium=c-search&utm_term= mallory weiss&utm_campaign=FH – Symptoms and Causes of Mallory-Weiss Syndrome – desktop&msclkid=0268c691ef941657973f9a5988c47db4Rich, K., PhD. (2018). Mallory-Weiss Syndrome. The Society for Vascular Nursing.inc. doi:10.1007/springerreference_109683You Tube documentary / Mallory-Weiss syndrome