Mallory-Weiss tear

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

active non-variceal bleeding

1st line – resuscitation plus supportive care

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1st line –

resuscitation plus supportive care

Prioritise resuscitation in line with standard ABC practice; protect the airway to prevent aspiration and obtain peripheral venous access. Follow your local protocol.

Give intravenous fluids to all patients.[31]

Monitor the patient using a validated early warning score (e.g., National Early Warning Score 2 [NEWS2]) and use clinical review to determine the infusion rate for your patient.[31] NEWS2 Opens in new window
Guidelines from the National Institute for Health and Care Excellence (NICE) in the UK and a consensus care bundle for acute upper gastrointestinal bleeding led by the British Society of Gastroenterology (BSG) recommend using a crystalloid solution as a bolus of 500 mL in less than 15 minutes in haemodynamically unstable patients.[31][54] The European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend prompt intravascular volume replacement using crystalloid fluids in haemodynamically unstable patients.[32]

Practical tip

Before diagnostic endoscopy consider intubating the patient if needed (e.g., if there is haematemesis, or there is a perceived risk of a haemodynamically unstable patient having blood in the stomach, or if the patient presents with an altered mental status).Make sure the patient is appropriately resuscitated before undergoing diagnostic endoscopy.

Request an urgent critical care review for any patient with ongoing haemodynamic instability despite adequate resuscitative efforts. Consider activating major haemorrhage protocols early.[31]

Consider seeking advice from an appropriate specialist if the patient is taking warfarin or a direct oral anticoagulant (DOAC).

The BSG consensus care bundle for acute upper gastrointestinal bleeding and the 2021 update to the BSG and ESGE guideline on endoscopy in patients on antiplatelet or anticoagulant therapy recommend:[31][64]
- Suspending DOACs at presentation and seeking advice from a haematologist when managing patients with severe haemorrhage to weigh up the risks and benefits of the DOAC
- Suspending warfarin at presentation
  - The BSG consensus care bundle stresses the importance of ensuring a plan is in place for restarting warfarin.[31] Consult a specialist to discuss the risks associated with stopping warfarin and the need for monitoring.[31][64]
In haemodynamically unstable patients, the 2021 update to the BSG and ESGE guideline recommends:[64]
- In patients who are taking warfarin, give intravenous vitamin K and four-factor prothrombin complex concentrate. Fresh frozen plasma can be used if prothrombin complex concentrate is not available
- If the patient is taking a DOAC, consider the use of reversal agents: idarucizumab in patients taking dabigatran, and andexanet alfa in patients taking anti-factor Xa. Intravenous four-factor prothrombin complex concentrate can be used if andexanet alfa is not available.
Note that NICE recommends:[33]
- Prothrombin complex concentrate in patients who are taking warfarin and actively bleeding
- Following local warfarin protocols to treat patients who are taking warfarin and whose upper gastrointestinal bleeding has stopped
- Recombinant factor Vlla (eptacog alfa) when all other methods have failed.

If any medications are temporarily stopped, also seek advice on the appropriate time for these to be restarted. The 2021 update to the BSG and ESGE guideline on endoscopy in patients on antiplatelet or anticoagulant therapy recommends restarting anticoagulation:[64]

As soon as possible after 7 days of anticoagulant interruption in patients with low thrombotic risk
Preferably within 3 days of anticoagulant interruption in patients with high thrombotic risk, with heparin bridging.

If the patient is taking aspirin, other non-steroidal anti-inflammatory drugs (including cyclooxygenase-2 [COX-2] inhibitors), or dual antiplatelet therapy:

In general, continue aspirin in the acute phase, if your patient is taking this for secondary prevention.[31][33][64]
- Consider seeking urgent advice from a specialist if there is major haemorrhage.
  - NICE doesn’t make a specific recommendation about major haemorrhage, but advises continuing aspirin only once haemostasis has been achieved.[33]
  - The consensus care bundle for acute upper gastrointestinal bleeding led by the BSG and the 2021 update to the BSG and ESGE guideline on endoscopy in patients on antiplatelet or anticoagulant therapy recommend continuing aspirin if this is taken as part of dual antiplatelet therapy with a P2Y₁₂ inhibitor (e.g., clopidogrel, prasugrel, ticagrelor), and the P2Y₁₂ is temporarily stopped.[31][64]
  - The 2021 update to the BSG and ESGE guideline recommends that, if aspirin is stopped, it should be restarted as soon as haemostasis is achieved or there is no further evidence of haemorrhage.[31][64]
  - The BSG care bundle cites two studies that demonstrate a three-fold increase in the risk of cardiovascular or cerebrovascular events if aspirin, prescribed for the secondary prevention, is discontinued.[31][66][67]
The 2021 update to the BSG and ESGE guideline recommends considering permanently discontinuing aspirin if the patient is taking it for primary prevention.[64]
If the patient is taking any other non-steroidal anti-inflammatory drugs (including COX-2 inhibitors), NICE recommends stopping these during the acute phase.[31]
If the patient is taking dual antiplatelet therapy, seek advice from the appropriate specialist to weigh up the benefits and risks of continuing the P2Y₁₂ inhibitor. Discuss the balance of benefits versus risk with your patient. In general, if the patient:[31]
- Does not have coronary artery stents, the P2Y₁₂ inhibitor should be stopped temporarily until haemostasis is achieved
- Does have coronary artery stents, dual antiplatelet therapy should ideally be continued due to the high risk of stent thrombosis. However, the risks and benefits of doing so need to be carefully considered by a specialist.

Consider – blood transfusion

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Consider –

blood transfusion

Additional treatment recommended for SOME patients in selected patient group

If the patient has massive bleeding, transfuse with blood, platelets, and clotting factors in line with your local protocols.[33]

Base decisions on blood transfusion on the full clinical picture; bear in mind that overtransfusion may be as damaging as under-transfusion.[33]
- The British Society of Gastroenterology consensus care bundle recommends to consider a higher trigger for transfusion than Hb <70 g/L in patients with ischaemic heart disease or haemodynamic instability.[31]
Give platelet transfusion to patients who are actively bleeding and have a platelet count of <50×10⁹/L.[31][33]
- Give fresh frozen plasma if the patient is actively bleeding and has a prothrombin time (or international normalised ratio) or activated partial thromboplastin time >1.5 times normal.[33]
- Give cryoprecipitate if the patient has a fibrinogen level that remains <1.5 g/L despite fresh frozen plasma.[33]

In haemodynamically stable patients follow a restrictive transfusion protocol (trigger: Hb <70 g/L; target: 70-100 g/L).[31]

Do not offer platelet transfusion if the patient is haemodynamically stable and not actively bleeding.[33]

Consider – anti-emetic

Plus – diagnostic endoscopy with or without endoscopic treatment

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Plus –

diagnostic endoscopy with or without endoscopic treatment

Treatment recommended for ALL patients in selected patient group

Following the risk assessment, consider patients with a Glasgow-Blatchford score ≤1 for outpatient management, in line with recommendations from the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE).[31][32] See Risk stratification under Diagnosis recommendations.

Refer all patients with suspected acute upper gastrointestinal (GI) bleeding for upper GI endoscopy (i.e., gastroscopy).[31][32][33] Follow your local protocol for recommendations on the optimal timing of the procedure for your patient. Guidelines from the National Institute for Health and Care Excellence (NICE) and the ESGE, and a consensus care bundle led by the BSG, agree that endoscopy should always be performed early (i.e., within 24 hours of presentation) with suspected acute upper GI bleed. However, the exact timing of the procedure within the 24-hour period is controversial, and specific recommendations from NICE, the BSG, and the ESGE differ as follows.

The ESGE recommends early (≤24 hours from presentation) upper GI endoscopy following haemodynamic resuscitation. The ESGE does not recommend urgent (defined by the ESGE as ≤12 hours from presentation) endoscopy.[32]
NICE and the BSG care bundle recommend:[31][33]
- Urgent endoscopy, immediately after resuscitation, if the patient is unstable with severe acute upper GI bleeding
- Endoscopy within 24 hours of admission for all other patients with upper GI bleeding.

Practical tip

Ensure that haemodynamically unstable patients are adequately resuscitated before undergoing diagnostic endoscopy.

For more on diagnostic endoscopy, see Imaging under Diagnosis recommendations.

After the endoscopy, review the endoscopy report and instructions from the endoscopist on the ward.[32]

Once the haemorrhage is confirmed by endoscopy, refer the patient to a gastroenterology service for endoscopic treatment.[31][33]

Endoscopic techniques are specialised and should only be undertaken by someone with adequate training and experience.

NICE recommends using one of the following methods for the endoscopic treatment of non-variceal upper gastrointestinal bleeding:[33]

A mechanical method (e.g., clips) with or without adrenaline (epinephrine)
Thermal coagulation with adrenaline
Fibrin or thrombin with adrenaline.

Do not use adrenaline as monotherapy for endoscopic treatment.[33]

Practical tip

Do not give proton-pump inhibitors pre-endoscopy. This is in line with recommendations from NICE guidelines and a consensus care bundle for acute upper GI bleeding led by the BSG.[31][33] NICE does not recommend the use of H2 antagonists before endoscopy.[33]

More info: Approaches to endoscopic treatment of non-variceal upper GI bleeding

Accepted endoscopic modalities include the following.

Injection therapy
- This is commonly used in the treatment of ulceration causing upper GI bleeding, in combination with thermal or mechanical therapy, or with fibrin or thrombin. Its role in the management of MWT bleeding has been studied in a small series.[69][70]
- Aliquots ranging from 0.5 to 20 mL are injected around or into the bleeding point.
Haemoclip placement, alone or in combination with adrenaline injection
- This is as safe and effective as other methods for controlling actively bleeding lesions.[71][72][73]
Thermal coagulation
- This includes multipolar electrocoagulation, heater probe, and argon plasma coagulation. Thermal coagulation is safe and often successful when given by experienced operators.[74][75]
Mechanical therapy
- Endoscopic band ligation (EBL) for MWT has been described in case reports and small randomised controlled trials. The mechanism is similar to that described for variceal band ligation: the affected mucosa is suctioned into the ligating cup device, after which a rubber band is deployed. EBL is simple and safe.[76][77][78] In most cases, EBL is used as a single therapy in which the bleeding point is aspirated and ligated. In practice, EBL may be considered as a treatment option in patients with uncontrollable bleeding from MWT.
- Cap-mounted clips are recommended by the ESGE guidelines in patients with persistent bleeding despite standard endoscopic treatments.[32] Persistent bleeding is defined as ongoing active bleeding refractory to standard haemostasis modalities.[32]
Topical therapy
- A topical hemostatic spray/powder is recommended by the ESGE for patients with persistent bleeding despite standard endoscopic treatments.[32]

[Figure caption and citation for the preceding image starts]: Mallory-Weiss tear after adrenaline injection (the bleeding has stopped, allowing better visualisation of the lesion)From the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].[Figure caption and citation for the preceding image starts]: Adrenaline 1:10,000 is injected intravenously next to Mallory-Weiss tearFrom the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].[Figure caption and citation for the preceding image starts]: Actively bleeding tear appears as a red longitudinal defect with normal surrounding mucosaFrom the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].[Figure caption and citation for the preceding image starts]: A haemoclip deployed in the centre of the lesion (no previous adrenaline was infused in this case)From the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].[Figure caption and citation for the preceding image starts]: Non-bleeding adherent clotFrom the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].[Figure caption and citation for the preceding image starts]: Three haemoclips deployed to complete closure of the mucosal defectFrom the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].

Consider – proton-pump inhibitor

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Consider –

proton-pump inhibitor

Additional treatment recommended for SOME patients in selected patient group

The National Institute for Health and Care Excellence (NICE) in the UK recommends giving a proton-pump inhibitor (PPI) post-endoscopy to patients with stigmata (a visible vessel and adherent blood clot) of recent haemorrhage shown on endoscopy; however, NICE does not make a specific recommendation on the preferred route of administration or dose.[33]

Note that the European Society of Gastrointestinal Endoscopy recommends high-dose PPI post-endoscopy for all patients who receive endoscopic treatments.[32]

Primary options

omeprazole: 80 mg intravenously initially over 40-60 minutes, followed by 8 mg/hour intravenous infusion for 72 hours, then switch to oral therapy

esomeprazole: 80 mg intravenously initially over 30 minutes, followed by 8 mg/hour intravenous infusion for 72 hours, then switch to oral therapy

Consider – emergency surgery or radiological intervention

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Consider –

emergency surgery or radiological intervention

Additional treatment recommended for SOME patients in selected patient group

Patients who rebleed after endoscopic and medical treatments may need emergency surgery or interventional radiology to control the bleeding.[32][33]

In patients who rebleed after first or failed endoscopic treatment, or are at high risk of rebleeding after endoscopic treatment, guidelines from the National Institute for Health and Care Excellence in the UK recommend:[33]

Repeat endoscopy for patients who rebleed with a view to perform further endoscopic treatment or emergency surgery
Interventional radiology for unstable patients who rebleed after endoscopic treatment. Refer the patient urgently for surgery if interventional radiology is not promptly available
Repeat endoscopy, with treatment as appropriate, for all patients at high risk of rebleeding, particularly if there is doubt about adequate haemostasis at the first endoscopy.

[Figure caption and citation for the preceding image starts]: 56-year-old female had a gastroscopy for upper GI bleeding 5 days prior treated with a single clip. She continued having melaena and low Hb for the following 5 days after initial procedure. A second gastroscopy detected a longitudinal gastric laceration without perforation on the corpus to cardiaFrom the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends]. 56-year-old female had a gastroscopy for upper GI bleeding 5 days prior treated with a single clip. She continued having melaena and low Hb for the following 5 days after initial procedure. A second gastroscopy detected a longitudinal gastric laceration without perforation on the corpus to cardia

[Figure caption and citation for the preceding image starts]: Diagnosed as a gastric tear without perforation from previous gastroscopy evaluation. Managed with application of haemoclips and emergency surgical consultFrom the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].[Figure caption and citation for the preceding image starts]: A total of seven haemoclips were appliedFrom the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends].[Figure caption and citation for the preceding image starts]: 16 days later, the tear has closedFrom the collection of Juan Carlos Munoz, MD, University of Florida [Citation ends]. 16 days later, the tear has closed

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Mallory-Weiss tear

active non-variceal bleeding

resuscitation plus supportive care

Practical tip

blood transfusion

anti-emetic

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

diagnostic endoscopy with or without endoscopic treatment

Practical tip

Practical tip

More info: Approaches to endoscopic treatment of non-variceal upper GI bleeding

proton-pump inhibitor

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

emergency surgery or radiological intervention

Mallory-Weiss tear

Treatment algorithm

active non-variceal bleeding

resuscitation plus supportive care

Practical tip

blood transfusion

anti-emetic

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

diagnostic endoscopy with or without endoscopic treatment

Practical tip

Practical tip

More info: Approaches to endoscopic treatment of non-variceal upper GI bleeding

proton-pump inhibitor

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

emergency surgery or radiological intervention