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MALLORY-WEISS AND BOERHAAVE SYNDROME Flashcards

1
Q

what is the definitions of mallory-weiss syndrome?

A

syndrome characterized by esophageal bleeding caused by a longitudinal laceration(S) at or near the gastroesophageal junction as a result of vomiting or retching

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2
Q

are single episodes or repeated episodes more of a typical presentation in mallory-weiss syndrome?

A

repeated episodes

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3
Q

is mallory-weiss syndrome more common in women or men?

A

men (3x more common in men)

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4
Q

what percentage of upper GI bleeds does mallory-weiss account for?

A

5-10%

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5
Q

what is the patho of mallory-weiss syndrome?

A
  1. rapid increase in intraabdominal pressure and intragastric pressure
  2. this pressure overcomes the lower esophageal sphincter pressure so the gastric contents are released into the esophagus
  3. normal autonomic reflexes cause the upper esophageal sphincter (UES) to relax
  4. this leads to vomitting
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6
Q

what RF is seen in 40-80% of patients with mallory-weiss syndrome that may also coexist with esophageal varices?

A

alcohol use!

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7
Q

what are the 4 RF for mallory-weiss syndrome other than alcohol?

A
  1. forceful or recurrent retching
  2. vomiting
  3. violent coughing spasm
  4. blunt abdominal trauma
  • events that create a sudden rise in pressure gradient across the gastroesophageal junction
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8
Q

what is a presenting symptom in all patients with mallory-weiss syndrome?

A

acute onset hematemesis

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9
Q

what is acute onset hematemesis?

A

vomitting blood
streaks of blood-> copious amounts of fresh red blood
- can be severe bleeding (variable amount)

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10
Q

what is acute onset hematemesis normally preceded by?

A

one or more episodes of non-bloody emesis, retching, or coughing

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11
Q

what is a HUGE clinical presentation in mallory weiss that is not acute onset hematemesis

A

epigastric or back pain

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12
Q

what can severe bleeding from acute onset hematemesis lead to?

A
  • shock (20% patients)
  • postural hypotension (45% of patients)
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13
Q

what clinical presentation is seen later in a patient dx with a tear in mallory weiss?

A

melena

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14
Q

what clinical presentation can someones with mallory weiss present with that is secondary to dehydration from underlying vomiting?

A

light headed, dizzy, syncopal

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15
Q

whats the study of choice for esophageal tears?

A

esophagogastroduodenoscopy

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16
Q

what does the EGD allow for?

A

allows for vosual inspection of esophagus, stomach, and duodenum

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17
Q

when can EGD be deferred?

A

pt w/ minimal bleeding and patient is stable..but pt should still be referred to GI

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18
Q

what if you have a pt with severe bleeding and hemodynamic instability but you want to do endoscopy?

A

STABILITY MUST BE OBTAINED PRIOR TO PERFORMING THE ENDOSCOPY

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19
Q

when are most tears difficult to visualize and why?

A

after 96 hours because that when most tears are well-healed

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20
Q

what are the 5 predictive factors for recurrent bleeding?

A
  1. initial presentation of shock
  2. hx liver cirrhosis
  3. decreased Hgb requiring blood transfusion
  4. low platelet count
  5. active bleeding at time of endoscopy
21
Q

HOW DO MOST EPISODES OF BLEEDING STOP?

A

SPONTANEOUSLY

22
Q

whats the tx for someone w/ a severe bleed (10% pts) in mallory weiss?

A
  1. close monitoring of vitals
  2. place 2 large bore IVs
    • fluid resuscitation
    • transfusion of PRBCs, if needed
23
Q

what labs do you get in mallory weiss?

A

CBC and coag assessment (PT/INR, PTT)

24
Q

what is the patient’s eating status initially during mallory weiss tx?

A

they’re initially NPO; bleeding resolved-> clear liquids

25
Q

what is the pharmacotherapy for mallory weiss tx?

A

IV proton pump inhibitor (PPI)

26
Q

what is a PPI used for?

A

acid suppression

27
Q

when is endoscopic hemostasis done as mallory weiss tx?

A

when a pt is hemodynamically unstable

28
Q

what is involved in endoscopic hemostasis?

A
  1. dilute epinephrine injections made 3-5 mm apart circumferentially around the site of bleeding
  2. electrocautery
  3. esophageal clips
  4. band ligation
29
Q

what are 2 other treatments for mallory weiss not mentioned?

A
  1. arteriography w/ embolizaiton
  2. surgical repair- rarely needed
30
Q

what is the definition of esophageal perforation?

A

spontaneous transmural perforation of esophagus exposing the mediastinum to GI contents

31
Q

what is the most common cause of esophageal perforation?

A

iatrogenic perforation (85-90%)
- endoscopic procedures or other instrumentation

32
Q

what are the other causes of esophageal perforation that are not iatrogenic?

A
  1. penetrating injuries (gunshot would>blunt injuries)
  2. foreign body ingestion
  3. spontaneous perforation/rupture (BOERHAAVE SYNDROME)
33
Q

what is the most lethal perforation of GI tract?

A

esophageal perforation -mortality 30%-> subsequent infection

34
Q

when are best outcomes of esophageal perforation achieved?

A

achieved from early dx and definite surgical management within 12 hours of rupture

35
Q

what does the patho of esophageal perforation depend on?

A

underlying cause

36
Q

what is the definition of boerhaaves syndrome?

A

sudden increase in intraluminal pressure in the esophagus, coupled with negative intrathoracic pressure, can lead to rupture

37
Q

what is the most common site of rupture in boerhaaves syndrome?

A

lower posterolateral third of esophagus

38
Q

what is the Mackler Triad seen in boerhaaves syndrome?

A
  1. vomiting
  2. severe retrosternal chest pain or epigastric pain
  3. subcutaneous emphysema
39
Q

when does subq emphysema in Macklers triad occur?

A

occurs when gas or air (generally from chest cavity) travels under the skin

40
Q

where does subq emphysema in Macklers triad occur?

A

on the chest, neck, and face

(wider neck diameter can be seen)

41
Q

does a boerhaaves or mallory weiss patient look sicker?

A

boerhaaves

42
Q

what other than macklers triad can a boerhaaves patient present with?

A
  1. Hematemesis: if present, dx is often mistaken for mallory-weiss tear
  2. chest pain
  3. dysphagia
  4. fever
  5. shock
43
Q

what diagnostic method suggests the dx of boerhaaves?

A

CXR
(START HERE)

44
Q

what diagnostic method confirms the dx of boerhaaves?

A

contrast esophagography (gastrograffin)

45
Q

what can a CXR show to suggest the dx of what boerhaaves?

A
  1. pneumomediastinum
  2. subcutaneous emphysema
46
Q

what does contrast esophagography (gastrograffin) aim to do?

A

see if there is contrast leakage from esophagus to mediastinum
determine length of perforation and its location

47
Q

when would a CT scan of the chest be perfromed in boerhaaves?

A

performed when:
1. CXR or esophagography is inconclusive
2. patient is unstable

48
Q

what is the initial treatment of boerhaaves?

A

Airway: ensure patency of airway
Breathing: ensure proper ventilation is occuring
Circulation: measure blood pressure and pulse, and administer IV fluids
Disability: perform basic neurologic exam
Exposure: search for injuries

49
Q

what are the other treatment methods for boerhaaves?

A
  1. close vital sign monitoring
  2. IV volume resuscitation
  3. NPO
  4. IV PPI
  5. admin of broad spectrum antibiotics
  6. prompt endoscopic stenting and/or surgical intervention

GI (22 decks)

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