Therapeutic alternatives for the Mallory-Weiss tear |
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Authors: | Pedro Morales Alex E Baum |
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Institution: | (1) Department of Medicine, Section of Gastroenterology and Hepatology, SL-35, Tulane University School of Medicine, 1430 Tulane Avenue, 70112 New Orleans, LA, USA |
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Abstract: | Opinion statement The Mallory-Weiss tear (MWT) is a frequent cause of upper gastrointestinal bleeding. It has been diagnosed more frequently
since endoscopy was introduced. Once the diagnosis has been made, several treatment options are available. The treatment modality
chosen depends on the type and location of the lesion, the patient’s comorbid conditions, the availability of the different
therapeutic modalities, and the experience of the endoscopist with each of these different modalities. In general, if the
MWT is not actively bleeding at the time of endoscopy, no further treatment is needed owing to a low risk of rebleeding, unless
a visible vessel is present. In the presence of a visible vessel or an actively bleeding vessel, then we recommend the use
of any of the endoscopic treatment modalities discussed later in this article depending on the patient’s condition and clinical
scenario. Our review of the literature suggests that multipolar electric coagulation (MPEC) is the treatment modality with
better evidence-based support for safety and bleeding control. MPEC has been associated only with very few complications.
It should be avoided when esophageal varices are suspected because it may precipitate and aggravate bleeding. In such instances,
either polidocanol injection or endoscopic band ligation of the tear is recommended, which is emerging as a safe and effective
treatment modality even in patients without varices. In addition, epinephrine injection is an effective first-line modality.
However, it should be avoided in patients with history of coronary artery disease owing to the potential for systemic absorption.
Endoscopic hemoclipping (EH) is another useful treatment option and is emerging as a first-line modality. However, it is not
widely available in all endoscopy emergency units. If it is available, it is a great alternative. Finally, if bleeding continues
or recurs despite endoscopic therapy, the patient should be referred for surgical treatment. However, if the patient is not
a surgical candidate, then radiologic hemostasis with selective vasopressin or Gelfoam embolization represents a viable treatment
alternative that may be used depending on availability of a specialized interventional radiologist. |
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