Mallory-Weiss syndrome: what is it, symptoms, treatment, prognosis

What is Mallory-Weiss Syndrome?

Mallory-Weiss syndrome (or Weiss, abbr. CMB) refers to a tear or laceration of the mucous membrane, most often at the place where the esophagus and stomach meet (gastroesophageal junction). Such a rupture can lead to severe bleeding from the gastrointestinal tract. The immediate cause of the lesion is usually a prolonged period of vomiting.

Signs and symptoms

Mallory-Weiss syndrome is most commonly characterized by abdominal pain, a history of severe vomiting, vomiting of blood (haemathesis), and severe involuntary vomiting. The blood is often coagulated and looks like "coffee grounds". The stool may be as dark as pitch (melenic). In cases where significant blood loss occurs, it is possible shock and collapse.

People with Mallory-Weiss syndrome may also experience severe, painless internal gastrointestinal bleeding (hemorrhage) due to ruptured mucous membranes. However, in most cases (80-90%), this bleeding stops spontaneously. In very rare cases, bleeding can become life-threatening.

Causes and risk factors

In most cases, severe vomiting is the immediate cause of Mallory-Weiss syndrome. It may be associated with chronic alcoholism, but CMB can also result from severe chest trauma or abdomen, chronic hiccups, intense snoring, lifting and straining, inflammation of the stomach lining (gastritis) or esophagus (esophagitis), diaphragmatic hernia, or CPR (cardiopulmonary resuscitation). Cancer patients undergoing chemotherapy may develop this disorder as a complication of chemotherapy.

Affected populations

Mallory-Weiss syndrome accounts for 1 to 15% of all gastrointestinal bleeding. However, it is more common in individuals with alcoholism. CMB seems to affect more men than women. The age of the victims varies considerably: the peak of the age category is 40-60 years. However, in some cases, the disease has occurred in children.

Symptomatic disorders

Symptoms of the following disorders may be similar to those of Mallory-Weiss syndrome. Comparisons can be useful for differential diagnosis:

• Zollinger-Ellison syndrome - a rare disease characterized by small tumors (usually in pancreas), which secrete a hormone that produces excess stomach acids that cause ulcers. These tumors can also appear in the lower wall of the stomach, spleen or lymph nodes near the stomach. Large amounts of stomach acid can be found in the lower stomach, where many ulcers form. Ulcers may appear suddenly even in areas where they are rare, may persist after treatment, and may be accompanied by diarrhea. To prevent complications such as bleeding and perforation, surgical treatment of these ulcers is necessary.
• Chronic erosive gastritis - widespread inflammation of the stomach, characterized by multiple lesions of the mucous membrane, causing ulcerative symptoms. These symptoms may include a burning sensation and a feeling of heaviness in the stomach pit, mild nausea, vomiting, loss of appetite and weakness. In severe cases, there may be stomach bleeding, which can lead to anemia. Some people with this disorder, especially those who regularly use aspirin, may not show symptoms until the disease progresses. An accurate diagnosis can be made by a physician by visual examination of the stomach using a gastroscope.
• Boerhaave syndrome - a very serious disease characterized by rupture of the esophagus. The rupture usually occurs from violent vomiting after eating too much. People with this disorder may have severe abdominal and chest pain, shortness of breath, and rapid heartbeat (tachycardia), bluish discoloration of the skin (cyanosis) and, ultimately, impaired circulation due to blood loss (shock) through the esophagus. Surgery is usually required to repair this type of fracture. It is important that this disorder is diagnosed in a timely manner so that treatment can be prescribed as soon as possible.
• Perforation of the esophagus - This is a rupture of the esophagus. When a tear occurs in the throat area, there may be neck swelling and constant pain that spreads from the chest to the back. If it occurs in the chest, there may be vomiting, pain in the upper abdomen, dyspnea and severe chest pain. This disorder can be caused by chemical burns in the throat, complications due to inflammation of the esophagus (esophagitis), stomach ulcer or abnormal growth (neoplasm). Diagnostic medical procedures such as endoscopy or gastroscopy can also cause esophageal perforation.
• Peptic ulcer - a very common disease characterized by damage to the mucous membranes of the esophagus, stomach or duodenum. Peptic ulcer disease is triggered by excessive secretion of acid or pepsin and is characterized by pain, heartburn, nausea and vomiting.
• Varicose veins of the esophagus is dilated, enlarged and tortuous veins, arteries, or lymphatic vessels at the lower end of the esophagus as a result of portal hypertension; they are superficial and prone to ulceration and massive bleeding.

The following disorder may be related to Mallory-Weiss syndrome. For differential diagnosis, it is not necessary:

• Chronic hiccups - sudden, involuntary repeated spasms of the diaphragm. They can last for hours or days, or they recur very often with only a few hours of relief between seizures. Persistent hiccups can indicate a serious medical condition. Some of the conditions that include persistent hiccups as a symptom are: pleurisy of the diaphragm, pneumonia, uremia, alcoholism, indigestion or esophagus, and bowel disease. Hiccups can also be associated with pancreatitis, pregnancy, bladder irritation, liver cancer, hepatitis, surgery, tumors, lesions, and gastroesophageal wounds.

Diagnostics

Doctors suspect a diagnosis of Mallory-Weiss syndrome in people who vomit blood after one or more episodes of vomiting. If the bleeding is minor, doctors may wait to get tested because the bleeding may stop on its own.

If the bleeding is heavy or does not stop on its own, doctors do an upper endoscopy. During an upper endoscopy, doctors examine the esophagus using a flexible tube called an endoscope. Upper gastrointestinal endoscopy allows doctors to see the cause of the bleeding and often treat it at the same time.

If the bleeding is rapid or heavy, doctors sometimes do angiography. During angiography, doctors use a catheter to inject liquid (contrast agent) into the artery, which is visible on x-rays.

Standard treatments

In many cases, the bleeding caused by Mallory-Weiss syndrome will stop without treatment. In cases where bleeding continues, treatment may include sealing the lesion by application of heat or chemicals (moxibustion) or high-frequency electric current (electrocoagulation).

Blood transfusion and / or vasopressive pitressin may be required. Among other actions, the hormone pitressin acts on the capillary muscles, affecting blood pressure. Direct pressure can also be used by inserting a catheter surrounded by a balloon. The balloon is then inflated (balloon tamponade) to stop the bleeding.

Surgery is usually not required if bleeding cannot be controlled by conservative measures. Surgery is usually not required unless the bleeding can be controlled with conservative measures. Other treatments are symptomatic and supportive.

Forecast

The prognosis for Mallory-Weiss syndrome (MWS) is generally good. Bleeding from foci stops spontaneously in 80-90% of patients. With conservative therapy, most tears heal without complications within 48-72 hours. Thus, CMB can be easily missed if endoscopy is delayed.

The degree of blood loss varies. Earlier studies reported that the proportion of patients requiring a blood transfusion was 40-70%. These numbers are probably much lower now.

Hemodynamic instability and shock can occur in 10% of patients with Mallory-Weiss syndrome. In one series, the mortality rate reached 8.6%; However, current clinical experience indicates a significantly lower mortality rate from SMV.

In one prospective 5-year study (2005-2009), Ljubicic et al found that mortality rates in high-risk patients with Mallory-Weiss syndrome were similar to those in patients with ulcerative bleeding. The researchers sequentially evaluated data from 281 patients with endoscopically confirmed Mallory-Weiss syndrome and 1530 patients with bleeding ulcers. Significant prognostic factors for both conditions included age over 65 years and the presence of significant comorbidities.

Complications

Complications such as ischemia or heart attack, hypovolemic shock, and death are usually associated with acute and severe bleeding and concomitant diseases. Fortunately, these complications are rare with the current standard of care.

Perforation or exacerbation of bleeding during endoscopic therapy is a potential complication, and organ ischemia and infarction are potential complications of angiotherapy.