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Mallory-Weiss Tears in Hospitalized Patients: Identifying the High-Stakes Bleeders and Mastering Mechanical Hemostasis
In this episode of Hospital Medicine Unplugged, we cut through the Mallory-Weiss tear—spot it fast, stop the bleed, stabilize smart, and endoscope right.
We open with the why and who: a longitudinal mucosal laceration at the gastroesophageal junction, triggered by vomiting, retching, or sudden pressure surges. Alcohol, reflux esophagitis, hiatal hernia, NSAIDs, coagulopathy, and liver disease stack the odds. It’s uncommon but not benign—~7.5/100,000 hospitalized patients, with a small but high-risk subset landing in the ICU.
Presentation pearls: classic sequence—retching then hematemesis—appears in <1/3 of cases. Hematochezia or shock = severe bleed. Keep an eye on cirrhotics, dialysis patients, and the elderly—they hide blood loss until they crash.
Diagnosis: stabilize first, scope early. EGD within 24 hours confirms the tear and rules out ulcers, varices, or Dieulafoy’s lesion. Imaging? Rarely needed unless endoscopy fails or perforation’s on the table.
Stabilization priorities:
• 2 large-bore IVs, crystalloids, restrictive transfusion (Hgb <7 g/dL unless cardiac or massive bleed).
• Reverse coagulopathy; correct platelets >50k, fibrinogen >120 mg/dL in liver disease.
• Airway protection if vomiting or altered.
• ICU admission for shock, cirrhosis, or hemodialysis.
Endoscopic game plan—mechanical first:
• Band ligation or hemoclips = best-in-class. Both achieve >95% hemostasis with minimal recurrence.
• Epinephrine injection is for temporary control—never solo for spurting bleeds.
• Combination therapy (epi + clip) works when mechanical access is tough.
• Nonbleeding tears? Observe, hydrate, PPI, discharge early if stable.
• If all fails—angiographic embolization or surgery (rarely needed).
Medical and supportive backbone:
• High-dose IV PPI → oral PPI transition once stable.
• Hold NSAIDs, antiplatelets, anticoagulants unless high thrombotic risk.
• Monitor for anemia, AKI, sepsis, and rebleeding.
• Refeed early in stable, nonbleeding patients—delays don’t help.
Special populations:
• Cirrhosis or coagulopathy: correct deficits, early endoscopy, and antibiotics if variceal source uncertain.
• Hemodialysis: gentle fluids, watch for overload, early scope.
• Massive bleeds: resuscitate, scope fast, consider mechanical endoscopy or TAE (transarterial embolization) if refractory.
Complications: bleeding anemia (26%), shock (3%), AKI, sepsis, and rare death (~2–3%). Rebleeding 2–12%, mostly in coagulopathic or cirrhotic patients.
Prognosis: excellent for most; poor in the elderly, cirrhotics, and those with shock.
Prevention & long game:
• Manage reflux, cut alcohol, stop NSAIDs.
• PPI prophylaxis for high-risk inpatients or post-bleed.
• Helicobacter pylori eradication if present.
• Multidisciplinary care = fewer readmissions, shorter stays, and safer outcomes.
We close with the system moves:
(1) Early EGD protocol for all upper GI bleeds.
(2) Restrictive transfusion + airway safety bundle.
(3) Mechanical-first endoscopic pathway (band or clip).
(4) ICU triage for cirrhosis/dialysis/shock.
(5) Post-bleed PPI and risk-factor modification.
(6) Track hemoglobin + rebleed signs before discharge.
Fast scope, tight stabilization, and mechanical mastery—that’s how you keep Mallory-Weiss tears from turning catastrophic.
View all episodes
By Roger Musa, MDIn this episode of Hospital Medicine Unplugged, we cut through the Mallory-Weiss tear—spot it fast, stop the bleed, stabilize smart, and endoscope right.
We open with the why and who: a longitudinal mucosal laceration at the gastroesophageal junction, triggered by vomiting, retching, or sudden pressure surges. Alcohol, reflux esophagitis, hiatal hernia, NSAIDs, coagulopathy, and liver disease stack the odds. It’s uncommon but not benign—~7.5/100,000 hospitalized patients, with a small but high-risk subset landing in the ICU.
Presentation pearls: classic sequence—retching then hematemesis—appears in <1/3 of cases. Hematochezia or shock = severe bleed. Keep an eye on cirrhotics, dialysis patients, and the elderly—they hide blood loss until they crash.
Diagnosis: stabilize first, scope early. EGD within 24 hours confirms the tear and rules out ulcers, varices, or Dieulafoy’s lesion. Imaging? Rarely needed unless endoscopy fails or perforation’s on the table.
Stabilization priorities:
• 2 large-bore IVs, crystalloids, restrictive transfusion (Hgb <7 g/dL unless cardiac or massive bleed).
• Reverse coagulopathy; correct platelets >50k, fibrinogen >120 mg/dL in liver disease.
• Airway protection if vomiting or altered.
• ICU admission for shock, cirrhosis, or hemodialysis.
Endoscopic game plan—mechanical first:
• Band ligation or hemoclips = best-in-class. Both achieve >95% hemostasis with minimal recurrence.
• Epinephrine injection is for temporary control—never solo for spurting bleeds.
• Combination therapy (epi + clip) works when mechanical access is tough.
• Nonbleeding tears? Observe, hydrate, PPI, discharge early if stable.
• If all fails—angiographic embolization or surgery (rarely needed).
Medical and supportive backbone:
• High-dose IV PPI → oral PPI transition once stable.
• Hold NSAIDs, antiplatelets, anticoagulants unless high thrombotic risk.
• Monitor for anemia, AKI, sepsis, and rebleeding.
• Refeed early in stable, nonbleeding patients—delays don’t help.
Special populations:
• Cirrhosis or coagulopathy: correct deficits, early endoscopy, and antibiotics if variceal source uncertain.
• Hemodialysis: gentle fluids, watch for overload, early scope.
• Massive bleeds: resuscitate, scope fast, consider mechanical endoscopy or TAE (transarterial embolization) if refractory.
Complications: bleeding anemia (26%), shock (3%), AKI, sepsis, and rare death (~2–3%). Rebleeding 2–12%, mostly in coagulopathic or cirrhotic patients.
Prognosis: excellent for most; poor in the elderly, cirrhotics, and those with shock.
Prevention & long game:
• Manage reflux, cut alcohol, stop NSAIDs.
• PPI prophylaxis for high-risk inpatients or post-bleed.
• Helicobacter pylori eradication if present.
• Multidisciplinary care = fewer readmissions, shorter stays, and safer outcomes.
We close with the system moves:
(1) Early EGD protocol for all upper GI bleeds.
(2) Restrictive transfusion + airway safety bundle.
(3) Mechanical-first endoscopic pathway (band or clip).
(4) ICU triage for cirrhosis/dialysis/shock.
(5) Post-bleed PPI and risk-factor modification.
(6) Track hemoglobin + rebleed signs before discharge.
Fast scope, tight stabilization, and mechanical mastery—that’s how you keep Mallory-Weiss tears from turning catastrophic.