A 34-year-old man presents to the emergency department (ED) after an episode of hematemesis. EGD confirms a Mallory-Weiss tear with no residual bleeding. Treatment should consist of:
A. EsophagectomyMallory-Weiss tears are characterized by arterial bleeding, which may be massive. Vomiting is not an obligatory factor, as there may be other causes of an acute increase in intraabdominal pressure, such as paroxysmal coughing, seizures, and retching. The diagnosis requires a high index of suspicion, particularly in the patient who develops upper gastrointestinal (GI) bleeding following prolonged vomiting or retching. Upper endoscopy confirms the suspicion by identifying one or more longitudinal fissures in the mucosa of the herniated stomach as the source of bleeding.
In the majority of patients, the bleeding will stop spontaneously with nonoperative management. In addition to blood replacement, the stomach should be decompressed and antiemetics administered, as a distended stomach and continued vomiting aggravate further bleeding. A SengstakenBlakemore tube will not stop the bleeding, as the pressure in the balloon is not sufficient to overcome arterial pressure. Endoscopic injection of epinephrine may be therapeutic if bleeding does not stop spontaneously. Only occasionally will surgery be required to stop blood loss. The procedure consists of laparotomy and high gastrotomy with oversewing of the linear tear. Mortality is uncommon, and recurrence is rare.