1804 An Unusual Presentation of Mallory-Weiss Syndrome (MWS)

Abstract

INTRODUCTION: Mallory-Weiss syndrome (MWS) is characterized as longitudinal mucosal tears of the esophagus, most often located in the gastro-esophageal junction that may extendproximally into the distal and even mid- esophagus or distally into the stomach. Risk factors for bleeding as a result of a tear include alcohol abuse and concomitant portal hypertension. Incidence is highest among the male gender and between the ages of 40-60. The proposed mechanism of the tearing is an increase in intra-abdominal pressure leading to a tear through the mucosa and underlying esophageal venous and/or arterial plexus. We present a unique case of MWS that originated in the mid-esophagus with no extended involvement of the distal esophagus. CASE DESCRIPTION/METHODS: A 51-year-old male with a past medical history of alcohol dependence presented to the ER for hematemesis. In the ER, the patient’s respiratory status rapidly declined and the patient was intubated. The lab values and chest xrays were all normal. After intubation, the patient continued with heavy retching that contained frank blood and clots. Emergent endoscopy was performed and a large mid-esophageal Mallory Wiess tear was identified and treated with epinephrine injections. There was also an ulceration of the GE junction that was treated with epinephrine and hemoclip placement. The patient recovered without further incident and was discharged several days later. DISCUSSION: Initial management of MWS with concomitant upper GI bleed includes: airway management, IV PPI, IV antiemetic, and upper endoscopy for evaluation of the tear with therapeutic interventions that may involve thermal coagulation, hemoclips, epinephrine injection, and/or band ligation. Complications often occur if bleeding cannot be controlled, and surgery may ultimately be necessary. As mentioned, MWS usually involves the gastro-esophageal junction. In a literature review, no previous cases involving a tear limited solely to the mid-esophagus were described until now. It is unclear as to what the pathophysiology behind this particular presentation is or if the location of the tear changes the prognosis and/or complication rate of the case. With no previous cases to review, recommendations are limited; however prompt management remains vital for all MWS cases.