Management of Mallory-Weiss Bleeding
A 37-year-old man presents after several episodes of forceful vomiting followed by two episodes of small volume hematemesis. Blood pressure is 112/63 mm Hg, heart rate 89 beats/min, respiratory rate 21 breaths/min, oxygen saturation 96% on room air. Hemoglobin is 135 g/L and white cell count 7.8 × 10⁹/L. Bleeding has not recurred. Which of the following is the most appropriate management plan?
- A.Conservative management with intravenous fluids and antiemeticsCorrect
- B.Immediate emergency upper gastrointestinal endoscopy
- C.Exploratory laparotomy with oversewing of the tear
- D.Balloon tamponade with a Sengstaken Blakemore tube
Explanation
The history of forceful vomiting followed by hematemesis points to a Mallory-Weiss tear. The decisive data are the haemodynamic and laboratory findings: normal blood pressure, a heart rate under 100 beats/min and a hemoglobin of 135 g/L, all indicating that blood loss has been minor. Between 80 and 90 percent of Mallory-Weiss tears stop bleeding spontaneously and heal within days without any intervention. Conservative management is therefore correct and comprises observation with serial vital signs and hemoglobin, intravenous fluids, a proton pump inhibitor to raise intragastric pH and promote healing, and antiemetics to stop further retching that would extend the tear. Endoscopy remains the definitive diagnostic test and should be performed within 24 hours as part of that conservative pathway, but an immediate emergency endoscopy is reserved for haemodynamic instability, ongoing bleeding or a falling hemoglobin. Endoscopic therapy with clips, thermal coagulation or adrenaline injection is used only when active bleeding or a visible vessel is found. Laparotomy is a last resort for massive uncontrolled bleeding and is inappropriate in a stable patient. Balloon tamponade is a rescue device for exsanguinating esophageal variceal bleeding in portal hypertension and has no role in a mucosal tear.
Why each option
- A.
- Correct. A haemodynamically stable patient with a normal hemoglobin and no ongoing bleeding is managed with fluids, acid suppression, antiemetics and observation.
- B.
- Emergency endoscopy is indicated for instability, ongoing bleeding or falling hemoglobin. In this stable patient endoscopy can wait and is done within 24 hours.
- C.
- Laparotomy with oversewing is a last resort for massive uncontrolled haemorrhage and would be grossly excessive here.
- D.
- Balloon tamponade applies pressure to bleeding esophageal varices in portal hypertension and has no role in a Mallory-Weiss tear.
Reference: ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding, Am J Gastroenterol 2021
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