Mallory–Weiss syndrome

Before 1929, there were cases reported with similar symptoms of bleeding in the esophagus, the first being Johann Friedrich Hermann Albers reporting ulcer in the lower esophagus in 1833 via autopsy; however those were caused by ulcers and not lacerations. Another instance of Mallory–Weiss syndrome was from 1879 when Dr. Heinrich Quincke discovered 3 cases of bleeding from the formation of ulcers in the gastroesophageal tube; 2 of the cases were fatal due to vomiting of blood. This was followed by 2 cases reported by Dieulafoy to witness death from the phenomenon via vomiting of blood and 100 more cases in later literature before the findings in 1929. It was hypothesized that repeated vomiting would lead to the formation of tears if the body was not able to coordinate the cardiac opening of the stomach with the contraction of the abdominal muscles to induce the vomiting. Dr. John Decker also examined patients afflicted with Mallory–Weiss syndrome via autopsy to note that many of patients did not have a history of alcoholism unlike the initial study conducted by the physicians the syndrome is named after; though Decker did comment that patients could be examined via gastroscope alongside Dr. Palmer who specifically mentioned the use of an endoscopy for diagnosis of Mallory–Weiss syndrome, so clinicians would not have to wait for a patient to die before performing an autopsy. However, a common finding between the patients with Decker's analysis is the exacerbation of the lesions caused by vomiting with atrophic gastritis being an underlying factor that to those formations; though atrophic gastritis is a condition that is common with the elderly population which most of the 11 patients undergoing an autopsy were above 60 years of age. when the only way in the past was to perform an autopsy when a patient is deceased. The following year, Hardy per the recommendations of Palmer and Decker was able to complete the first diagnosis of the syndrome via endoscopy, leading to an increased incidence of Mallory–Weiss syndrome as shown with over 200 cases being mentioned in the literature as of 1973, and eventually the standard to make use of endoscopy to diagnosis the condition to witness lacerations along the esophageal lining and the signs of hemorrhage. ==Signs and symptoms==

Mallory–Weiss syndrome often presents as an episode of vomiting up blood (hematemesis) after violent retching or vomiting, or due to undigested food residues but may also be noticed as old blood in the stool (melena), and a history of retching may be absent. Oftentimes, hematemesis is accompanied by chest, back, or epigastric pain. The condition is rarely fatal since in 90% of cases the tears heal on their own and the bleeding will stop spontaneously within 48 to 72 hours. However, endoscopic or surgical treatment may be necessary for severe bleeds. In cases of more severe bleeding, the typical symptoms of Mallory-Weiss Syndrome are those typical found in shock, which can be life-threatening. Although there are multiple types of shock, hemorrhagic hypovolemic shock is most commonly associated with gastrointestinal bleeding. Furthermore, gastrointestinal losses, such as those incurred from prolonged vomiting or diarrhea are associated with non-hemorrhagic hypovolemic shock. Both hemorrhagic and non-hemorrhagic hypovolemic shock can occur when there are decreases in intravascular volume, such as when the body is hemorrhaging (bleeding) or significant fluid loss. This decrease in intravascular volume causes subsequent reflex mechanism produced by the body to activate SANs (sympathetic nervous system) in the later stages of hypovolemic shock. SANs is activated in response to the drop in mean arterial pressure that is brought on by the loss of fluid. ==Causes==

The causes of Mallory–Weiss syndrome is often associated with alcoholism, eating disorders such as bulimia nervosa, and gastroesophageal reflux disease (GERD). Specifically, up to 75% of patients have been observed with a heavy alcohol use associated with emesis. It is also significantly noted in recent research by Arora S et al. that it is associated with undigested food residues. It is also thought that Mallory–Weiss syndrome can be caused by actions that cause sudden increases in intra-abdominal pressure, such as repeated severe vomiting or coughing. There is conflicting data suggesting the association between hiatal hernias and Mallory–Weiss syndrome. In 1989, a study conducted in Japan set out to determine if there was a link to Mallory–Weiss syndrome and hiatal hernias, this study found that hiatial hernias were found in 75% of patients with Mallory–Weiss syndrome. On the contrary, a case-control study in 2017 found there was no association between hiatal hernias and Mallory–Weiss syndrome. NSAIDs can increase the risk of upper gastrointestinal bleeding because they can cause further damage to the intestinal submucosa by inhibiting prostaglandin synthesis. In rare instances some chronic disorders like Ménière's disease that cause long term nausea and vomiting could be a factor. Other potential risks for GI bleeds are usage of anticoagulants and older age. Additionally, studies that were performed in patients with cirrhosis (scaring/fibrosis of the liver) who also had portal hypertension have shown that an increase in portal pressure can cause an increase in intra-abdominal pressure. These increases in intra-abdominal pressure are associated with Mallory-Weiss Syndrome. More severe upper gastrointestinal bleeds are associated with concurrent portal hypertension and esophageal varices. Additionally, esophageal varices can rupture which can be fatal. Most patients are between the ages of 30 and 50 years, although it has been reported in infants aged as young as 3 weeks, as well as in older people. Hyperemesis gravidarum, which is severe morning sickness associated with vomiting and retching in pregnancy, is also a known cause of Mallory–Weiss tear. There have been a few complications from invasive procedures such as trans-esophageal echocardiography and upper gastrointestinal endoscopy that cause Mallory-Weiss tears called iatrogenic Mallory–Weiss syndrome. The individuals did not have a history of alcoholism, hiatal hernia, or gastrointestinal diseases, but woke up vomiting blood. ==Diagnosis==

Definitive diagnosis of Mallory-Weiss tears is by upper GI endoscopy of the esophagus and stomach. Typically, the tear is located near the top of the stomach's lesser curvature and below the gastroesophageal junction. In the majority of patients, tears usually range from approximately 2 to 4 cm in length. The findings may include indications of non-bleeding, active bleeding, or the presence of clot over the tear. Proper history taking by the medical doctor to distinguish other conditions that cause haematemesis but definitive diagnosis is by conducting esophagogastroduodenoscopy, which is a procedure that allows the oropharynx, esophagus, stomach, and proximal duodenum (beginning of the small intestine) to be visualized. ==Treatment==

The course of treatment and management of Mallory–Weiss syndrome depends on the amount of bleeding or hematemesis. Although blood transfusion is ultimately needed for many patients with Mallory–Weiss syndrome, 90% of Mallory-Weiss tears can heal on their own spontaneously. If the bleeding is mild and localized, the condition can be managed with conservative treatment methods such as intravenous antacids, antiemetics, fasting, and bedrest. Antiemetics are medications used to help with nausea and vomiting. However, if constant bleeding is observed upon endoscopy, endoscopic hemostasis techniques are necessary as the first-line treatment. Four examples of endoscopic hemostasis techniques are hemoclipping, heat probe thermocoagulation, injection therapy, and band ligation. Although hemoclip placement is a convenient procedure for nonfibrotic tissue, such as Mallory–Weiss syndrome, placing a hemoclip can be challenging at the typical location of Mallory-Weiss tears at the gastroesophageal junction. Thermocoagulation with bipolar or multipolar electrocautery can be employed to cauterize tissue. It is most appropriate for small and localized lesions that require minimal cauterization. However, it should be avoided in patients with esophageal varices as the absence of a serosal layer in the esophagus increases susceptibility to perforation and could exacerbate bleeding, posing significant risks. It is also noted that repeated coagulation therapy can lead to risk of transmural injury. or cauterization However, this method requires close monitoring due to the possibility of causing ventricular tachycardia when administered submucosally. Thus, epinephrine injections should not be used in patients who have existing cardiovascular conditions. Furthermore, proton pump inhibitors have a decreased recurrent bleeding rate and do not lose their efficacy as a side effect when taken regularly over time (tachyphylaxis) compared to H2 receptor antagonists. Additionally, antiemetics such as promethazine are given to control nausea and vomiting as part of the treatment regimen. == See also ==