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Mallory Weiss Syndrome - Upper GI Bleed from Longitudinal Mucosal Tear
- 1. Mallory Weiss Syndrome Dr.Nafeeya Department of Forensic Medicine &Toxicology
- 2. Overview • Introduction • Risk factors & Causes • Pathogenesis • Differential diagnosis • Histopathology • Autopsy findings • Medicolegal importance
- 3. Introduction • Common causes of acute upper gastrointestinal bleeding • longitudinal superficial mucosal tears • Primarily at the gastro esophageal junction • Heal within 7 to 10 days without treatment • Significant bleeding
- 4. Anatomy
- 5. The esophageal wall contains four layers: • Mucosa—surface epithelium, lamina propria, and glands. • Submucosa—connective tissue, blood vessels, and glands. • Muscularis (middle layer) upper third, striated muscle. • Adventitia—connective tissue that merges with connective tissue of surrounding structures.
- 6. Upper GI bleed secondary to longitudinal mucosal tear –Mallory Weiss Syndrome
- 7. Risk factors
- 8. Causes
- 9. Pathogenesis • Shearing force • Non transmural tear of oesophagus • Partial thickness tear • Tear-gastroesophageal junction • Length - < 1 inch or 2.5 cm
- 10. Predisposing factors (vomiting ,procedures) Intra-abdominal pressure Large transient transmural pressure gradient Acute distension Mallory Weiss tear(longitudinal mucosal tear at GEJ) Shearing forces > Transmural pressure gradient
- 11. Rupture of sub-mucosal arteries Upper GI bleed Coffee ground emesis Melena Blood lost from systemic circulation Blood oxidized & passed through GI Hematemesis ,Hematochezia Tachycardia ,HT,Anaemia ,Syncope Rapid blood loss & expulsion
- 13. Boerhaave”s syndrome Spontaneous esophageal perforation following forceful vomiting
- 14. Mallory Weiss Syndrome Boerhaave syndrome Partial thickness-Superficial mucosal tear Full thickness-Transmural tear Incomplete tear only affects mucosa & submucosa Complete rupture at the lower thoracic esophagus . Gastroesophageal junction Distal posterolateral esophagus History of vomiting & retching ,abdominal or chest pain Vomiting, lower thoracic pain etc. Endoscopy .Resolves spontaneously CT ,Chest x-ray .Needs emergency treatment Myocardial ischemia or infarction, hypovolemic shock, and death Sepsis leading to multiorgan failure and death
- 16. •Upper third – skeletal muscles. •Middle third – smooth muscles & skeletal muscles •Bottom – smooth muscles
- 17. Mallory azan stain Nuclei – red Muscle –orange Collagen – blue
- 18. Longitudinal breach of the mucosa that extends into the submucosa Hemorrhage, either with or without an acute inflammatory response
- 19. Esophagus Dissection The esophagus is opened through its posterior wall and the inner aspect examined
- 20. The oesophagus is dissected free to reveal the underlying trachea. The trachea is opened with scissors through its posterior muscular wall
- 21. Autopsy findings Effusion of blood Esophageal tear in the right lateral wall
- 24. Medicolegal importance • Autopsy , Microscopic Findings, Clinical Data • Sudden & unexpected cause of death • The established cause of natural death was fatal exsanguination from esophageogastric mucous tears
- 25. Reference • Anil Aggrawal textbook of forensic medicine and toxicology • Narayana reddy text book of forensic medicine and toxicology • Harsh Mohan Textbook of Pathology, 7th edition • Robbins & cotran basis of disease pathology. • Atlas of histology –Lippincotts williams &wikins • Case report Maria Cuccì et al-Transition of a Mallory-Weiss syndrome to a Boerhaave syndrome confirmed by anamnestic, necroscopic, and autopsy data • Harjot atwal et al –mallory weiss tear The callory guide to understand disease
Editor's Notes
- a tear or laceration of the mucous membrane, most commonly at the point where the esophagus and the stomach meet (gastroesophageal junction). Such a tear may result in severe bleeding from the gastrointestinal tract. transient transmural pressure gradient across the region of the gastroesophageal junction.
- Mallory-Weiss syndrome is one of the common causes of acute upper gastrointestinal (GI) bleeding, characterized by the presence of longitudinal superficial mucosal lacerations (Mallory-Weiss tears). These tears occur primarily at the gastroesophageal junction; they may extend proximally to involve the lower or even mid esophagus and at times extend distally to involve the proximal portion of the stomach.
- The esophageal functions are to transport food from the mouth to the stomach and to prevent reflux of gastric contents.
- The esophagus is a muscular tube about ten inches (25 cm.) long, extending from the hypopharynx to the stomach. The esophagus lies posterior to the trachea and the heart and passes through the mediastinum and the hiatus, an opening in the diaphragm, in its descent from the thoracic to the abdominal cavity. The esophagus has no serosal layer; tissue around the esophagus is called adventitia.
- In this condition, there is lacerations of mucosa at the gastro-oesophageal junction following minor trauma such as by vomiting, retching or vigorous coughing. Patients present with upper gastroesophageal bleeding.
- Lap antireflux surgery . esophageal dialation ,biopsy
- Endoscopic ,esophageal dialation ,biopsy ,
- likely from expulsion of gastric content
- mucosal lacerations develop secondary to a sudden increase in intraabdominal pressure. Bleeding occurs when the tear involves the underlying esophageal venous or arterial plexus.
- Boerhaave syndrome: A severe condition that shares the same predisposing factors with Mallory-Weiss syndrome, but the pathology is perforation of the esophagus Esophageal varices: Dilated tortuous vessels around the lower esophagus, mostly as a complication of portal hypertension. Esophageal varices may also coexist with Mallory Weiss syndrome.
- BMW-Intraesophageal pressure along with negative intrathoracic pressure.
- longitudinal breach of the mucosa that extends into the submucosa, but generally not into the muscularis propria, usually accompanied by hemorrhage, either with or without an acute inflammatory response.Neutrophil infiltration of the esophageal mucosa Presence of hemosiderin accumulations in the esophageal mucosa
- Two or more linear tears in the mucosa of the esophagastric junction as the sole lesion responsible for exsanguinating hemorrhage.
- Autopsy revealed Gastric content in pleural space
- Severe blood loss