MALLORY-WEISS SYNDROME.pptxxxxxxxxxxxxxx

nill

1. MALLORY-WEISS SYNDROME By: Dr. J. K. Sesay Senior Registrar, MOHS Specialist: General Surgeon Dip. Int. Health, M.D., M.Med. Surgery USLTHC, Connaught

2. OUTLINE Summary Definition Epidemiology Etiology Clinical features Diagnostics Differential diagnosis Treatment Acute management checklist References

3. SUMMARY Mallory-Weiss syndrome refers to acute  upper gastrointestinal bleeding  caused by  mucous membrane  lacerations at the  gastroesophageal junction , although it may extend above or below. Forceful vomiting in the presence of a damaged gastric  mucous membrane , often related to  alcoholism , is a common cause of Mallory-Weiss syndrome. Patients typically present with a history of epigastric  pain  and  hematemesis .  Esophagogastroduodenoscopy  is important in both the diagnosis of the condition and its treatment, which involves simultaneous  hemostasis .

4. DEFINITION Upper gastrointestinal bleeding  caused by tears to the longitudinal mucous membrane at the gastroesophageal junction. Tears may extend above or below the  gastroesophageal junction . EPIDEMIOLOGY Sex :  ♂  >  ♀  (3:1) Mallory-Weiss lesions account for approx. 5% of cases of  gastrointestinal bleeding

5. TREITZ LIGAMENT

6. ETIOLOGY Mechanism : A sudden and severe rise in the esophageal intraluminal pressure results in tearing of the esophageal  mucous membrane , as well as the  submucosal   arteries  and  veins Precipitating factors Severe vomiting Blunt abdominal trauma Strained defecation Predisposing conditions Alcoholism Bulimia nervosa Hiatal hernia (higher pressure gradient) Gastroesophageal reflux disease  ( GERD )

7. CLINICAL FEATURES (a) May be asymptomatic (b) Epigastric or back  pain (c) Hematemesis   (d) Possible  shock  with massive hemorrhage  DIAGNOSTICS Esophagogastroduodenoscopy o ften a single longitudinal tear (multiple tears are possible) in the  mucosa  at the  gastroesophageal junction ; limited to  mucosa  and  submucosa A clot or active bleeding may be evident.

8. DIFFERENTIAL DIAGNOSIS Boerhaave Syndrome : a spontaneous perforation of the esophagus that results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure Esophagitis : is inflammation that may damage tissues of the esophagus Esophageal  ulcers : An esophageal ulcer is a type of peptic ulcer that develops in the lining of the esophagus. Esophageal ulcers occur when the layer of mucus, which lines and protects the gastrointestinal tract, wears away.

9. TREATMENT General measures If bleedings stops spontaneously  conservative treatment  is usually sufficient Control of precipitating factors (e.g., omeprazole for  GERD ) Inpatient monitoring Treat hemodynamic instability if present Surgical treatment Indication: actively bleeding lesion Gold standard:  esophagogastroduodenoscopy Therapeutic injection of an  adrenaline  solution or a  fibrin  sealant Electrocoagulation Endoscopic band ligation Second-line treatment: angiography  (embolization,  vasopressin  infusion)

10. ACUTE MANAGEMENT CHECKLIST   IV access IV fluid resuscitation Check  CBC ,  coagulation panel ,  type and screen Identify and treat any  coagulopathy Consider the need for blood and  platelet transfusion GI consult for consideration of endoscopic  hemostasis If endoscopic methods fail: IR consult for transcatheter arterial embolization   Surgery consult for surgical intervention

11. Checklist contd.   Antiemetic therapy Ondansetron  Metoclopramide   Acid suppression  Proton pump inhibitors Omeprazole  Pantoprazole  H 2  antagonists :  ranitidine Alcohol cessation counseling Continuous  pulse oximetry , frequent  blood pressure measurement Order serial  CBC , monitor for signs of bleeding Consider  ICU  admission if hemodynamically unstable

12. REFERENCES 1.Song LMWK. Mallory-Weiss Tear Overview of Mallory-Weiss Syndrome. In: Katz J  Mallory-Weiss Tear Overview of Mallory-Weiss Syndrome . New York, NY: WebMD. http ://emedicine.medscape.com/article/187134-overview#showall . June 25, 2015. Accessed January 4, 2017. 2.Guelrud M. Mallory-Weiss syndrome. In: Post TW, ed.  UpToDate  .Waltham, MA: UpToDate. https ://www.uptodate.com/contents/mallory-weiss-syndrome . Last updated March 18, 2014. Accessed January 4, 2017. 3.Kim H-S. Endoscopic Management of Mallory-Weiss Tearing.  Clin Endosc  .2015; 48(2): p.102. doi:  10.5946/ce.2015.48.2.102 . | Open in Read by QxMD 4.Loffroy R, Favelier S, Pottecher P, et al. Transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding: Indications, techniques and outcomes.  Diagn Interv Imaging  .2015; 96(7-8): p.731-744. doi:  10.1016/j.diii.2015.05.002 . | Open in Read by QxMD