10 MALLORY WEISE TEAR Running head: MALLORY WEISE TEAR 1 Running head: MALLORY WEISE TEAR Introduction The following information will be an extensive in-depth review of a patient with a condition known as a Mallory Weise Tear (MWT). The paper will analyze peer-reviewed literature surrounding this condition and the pathophysiology behind it. There are complications that can arise with a diagnosis of an MWT, so the paper will discuss how to recognize the warning signs and how to manage patient care. The paper will also cover the nursing process and treatments for a patient that suffers from MWT. Last but not least, the paper will cover suggested teachings that nurses can go over with their patient and family on the how’s and why’s, along with signs and symptoms of MWT and its complications. Scenario A 57-year-old male presents to the emergency department with complaints of abdominal pain, dark black stools for the last four days, and having coffee ground emesis with occasional red streaks. He states a past medical history that includes mild cirrhosis related to alcohol abuse, current smoker of one pack per day, and chronic back pain from an MVA ten years ago that he treats with Aleve and ibuprofen. He has been told that he has hypertension but does not take any medication. On examination, the vital signs are as follows: blood pressure 138/84, heart rate 105, tympanic temperature 98.9, respirations 19, O2 saturations 98% on room air. He complains of nausea and is guarding his abdomen. There is no asities or obvious jaundice noted. Upon auscultation the patient has normal heart tones and clear breath sounds bilaterally. The doctor was at the bedside and performed a digital rectal exam which reveals black stool, occult blood positive. An 18g IV was stared in his right antecubital vein and labs were sent. The labs showed the following: WBC 11, HGB 8.4 g/DL, HCT 25 %, PLT 150 K/UL, AST 78 U/L, ALT 54 U/L, Albumin 3.5 G/DL, Ammonia level 15 U/DL, Potassium 3.7 mEq/l, Sodium 135mEq/l, BUN 25 mg/dl, Creatinine 1.1 mg/dl, Glucose 96 mg/dl. The doctor mentions that most of the labs are with in normal limits but could be indicative of a hemorrhage. Literature Review E. Cherednikov, A.A. Kunun, E.E. Cherednikov, and N.S. Moiseeva (2016), authors of “The Role of Etiopathogenetic Aspects in Prediction and Prevention of Discontinuous-Hemorrhagic (Mallory-Weiss) Syndrome,” provided numerous etiological factors, and new insights into the pathogenesis of the disease. S.S. Flanders (2018), author of “Effective Patient Education: Evidence and Common Sense,” takes a close look at patient education related to MWT, and what aspects are most beneficial for knowledge retention. K. Hyun-Soo (2015), author of “Endoscopic Management of Mallory-Weiss tearing,” discusses surgical, nonsurgical options, and treatments available. J. Jahraus (2018), author .

1. 10
MALLORY WEISE TEAR
Running head: MALLORY WEISE TEAR
1
Running head: MALLORY WEISE TEAR
Introduction
The following information will be an extensive in-depth review
of a patient with a condition known as a Mallory Weise Tear
(MWT). The paper will analyze peer-reviewed literature
surrounding this condition and the pathophysiology behind it.
There are complications that can arise with a diagnosis of an
MWT, so the paper will discuss how to recognize the warning
signs and how to manage patient care. The paper will also
cover the nursing process and treatments for a patient that
suffers from MWT. Last but not least, the paper will cover
suggested teachings that nurses can go over with their patient
and family on the how’s and why’s, along with signs and
symptoms of MWT and its complications.
Scenario
A 57-year-old male presents to the emergency department with
complaints of abdominal pain, dark black stools for the last four
days, and having coffee ground emesis with occasional red
streaks. He states a past medical history that includes mild

2. cirrhosis related to alcohol abuse, current smoker of one pack
per day, and chronic back pain from an MVA ten years ago that
he treats with Aleve and ibuprofen. He has been told that he
has hypertension but does not take any medication.
On examination, the vital signs are as follows: blood pressure
138/84, heart rate 105, tympanic temperature 98.9, respirations
19, O2 saturations 98% on room air. He complains of nausea
and is guarding his abdomen. There is no asities or obvious
jaundice noted. Upon auscultation the patient has normal heart
tones and clear breath sounds bilaterally. The doctor was at the
bedside and performed a digital rectal exam which reveals black
stool, occult blood positive. An 18g IV was stared in his right
antecubital vein and labs were sent. The labs showed the
following: WBC 11, HGB 8.4 g/DL, HCT 25 %, PLT 150 K/UL,
AST 78 U/L, ALT 54 U/L, Albumin 3.5 G/DL, Ammonia level
15 U/DL, Potassium 3.7 mEq/l, Sodium 135mEq/l, BUN 25
mg/dl, Creatinine 1.1 mg/dl, Glucose 96 mg/dl. The doctor
mentions that most of the labs are with in normal limits but
could be indicative of a hemorrhage.
Literature Review
E. Cherednikov, A.A. Kunun, E.E. Cherednikov, and N.S.
Moiseeva (2016), authors of “The Role of Etiopathogenetic
Aspects in Prediction and Prevention of Discontinuous-
Hemorrhagic (Mallory-Weiss) Syndrome,” provided numerous
etiological factors, and new insights into the pathogenesis of the
disease. S.S. Flanders (2018), author of “Effective Patient
Education: Evidence and Common Sense,” takes a close look at
patient education related to MWT, and what aspects are most
beneficial for knowledge retention. K. Hyun-Soo (2015), author
of “Endoscopic Management of Mallory-Weiss tearing,”
discusses surgical, nonsurgical options, and treatments
available. J. Jahraus (2018), author of “Medical Complications
of Eating Disorders,” discusses eating disorders that contribute
to MWT. Specifically, conditions discussed are those that
involve self-induced vomiting. D.T. Martin, and M.A.
Schreiber (2014), authors of “Modern Resuscitation of

3. Hemorrhagic Shock: What is on the horizon?”, this article
explored the pathophysiology, diagnosis, and treatment of
hemorrhagic shock, a subset of hypovolemic shock. B. Nojkov
and M.S. Cappell (2016), authors of “Distinctive Aspects of
Peptic Ulcer Disease, Dieulafoy's lesion, and Mallory-Weiss
Syndrome in Patients with Advanced Alcoholic Liver Disease or
Cirrhosis,” discusses distinctive aspects of advanced liver
disease and cirrhosis of the liver, as it relates to patients with
MWT. K. Rich (2018), author of “Overview of Mallory-Weiss
Syndrome,” discusses the medical diagnosis of MWT in general.
Pathophysiology
Mallory and Weiss presented the cause of upper gastrointestinal
bleeds not associated with peptic ulcers or non-variceal upper
gastrointestinal bleeds. The MWT represents a tear or
laceration in the mucosa lining in the stomach or
gastroesophageal junction. There are different severities when
talking about MWT meaning that some are far worse than
others. An MWT can result from actual physical trauma to the
area. Most often MWT is associated with alcohol induced
vomiting that causes an increase in intraesophageal pressure
caused by prolonged severe vomiting. Aside from alcohol,
development of an MWT can also be associated with eating
disorders, violent hiccups, hiatal hernia, gastritis, and the
overuse of non-steroidal anti-inflammatory drugs. Some of the
physical traumatic causes for an MWT can be linked to
transesophageal echocardiograms,
esophagogastroduodenoscopy, and blunt abdominal trauma. The
combination of a weakened mucosal lining and increased
esophageal pressure increased the chances of having an MWT
(Cherednikov, Kunun, Cherednikov, & Moiseeva, 2016).
Nursing Process
Nursing Actions
When the patient is presenting with gastrointestinal bleed there
are some common nursing actions that need to be done. The
nurse can anticipate starting one if not two large bore IV
catheters. This would be wise incase the patient does need

4. blood products. Blood must be administered by itself, therefor
necessitating the second line to run fluids. The nurse can
expect to give packed red blood cells (PRBC’s) and if there is a
coagulopathy problem, then other blood products such as fresh
frozen plasma (FFP), platelets, and possibly cryoprecipitate can
be used. Having a second site will also allow IV fluids, like
isotonic solutions to be given to replace fluid loss. The
registered nurse will need to get a complete set of vital signs,
complete a physical assessment, and a throughout health history
assessment to help determine the cause of the MWT. Labs will
be ordered so the nurse should be on the lookout for those
results and report any abnormalities to the doctor right away.
With any gastrointestinal bleed, the nurse needs to be vigilant
in assessing for increased bleeding such as vomiting bright red
blood, and the subtle signs of hemodynamic instability which
are increased heart rate and lower blood pressure. Medications
There is no specific medication that treats MWT, medications
are used to treat the common causes of MWT. A proton pump
inhibitor (PPI) can be prescribed to decrease the acidity of
gastric acid and reduce the erosions of the mucosal lining. The
registered nurse should be prepared to administer an antiemetic
medication to suppress and treat nausea and vomiting. Some of
the more common PPI’s you will see are Protonix and
Omeprazole. These medications decrease the amount of acid
your stomach makes. Zofran, Phenergan, and Compazine are
medications used to treat nausea and vomiting. If your patient
is on anticoagulation therapy for any reason, you could be
administering the reversal medication. Some examples of this
would be if your patient was on Coumadin then Vitamin K and
possibly fresh frozen plasma will be ordered to reverse the
medications effects. Some of the antiplatelet medications do
not have an antidote, so depending on the severity of the bleed,
a transfusion of platelets may be ordered (Davis Drug Guide,
2017).
Pertinent Specific Treatment
Most patients that suffer from an MWT do not need more than

5. close hemodynamic monitoring, fluid resuscitation, and rest
from the underlying cause to treat the condition. However, the
degrees of an MWT can vary greatly and a more complicated
bleed could occur that requires further invasive interventions.
When diagnosing MWT, an endoscopy is performed by the
doctor. If the bleed is severe, they have a few options for
treatment to choose from. They will localize the bleed and the
doctor will inject epinephrine around the site, this is the most
common drug treatment for local injections. If the injections do
not stop the bleeding, there are clips and bands that can be
deployed to stabilize the area. If hemostasis cannot be
achieved, then the patient will have to go for emergency surgery
to cauterize the vessel (Hyun-Soo, 2015).
Coagulation studies, hemogram, and electrolyte panel will be
performed for all patients suffering from an MWT.
Coagulopathies will be treated with either medication reversal
agents or blood products. Electrolyte and fluid replacement
may be needed due to prolonged vomiting and dehydration. If
hemoglobin is low and the patient is hemodynamically unstable,
a blood transfusion may be ordered (Nojkov & Cappell, 2016).
Comfort Measures
This can be a stressful time and diagnosis for patients and their
families. Some comfort measures that the nurse can facilitate
for the patient to help ease the anxiety include active listening
to the patient and family concerns. The nurse should
collaborate with chaplain services to help ease the anxiety of
the patient and family members. Also providing education and
utilizing the hospitals multidisciplinary team to help find
outside resources to help alleviate the stress or concerns the
patients or family have. Guided imagery can be used as an
alternative method for pain relief. Music therapy can be used to
distract the patient from pain. When the patient can eat again,
offering soft foods or cold liquids (patients’ preference) to help
alleviate his or her sore throat.
Safety Issues
The safety issues to be concerned with when you have a patient

6. with MWT, are based on the assessment and the treatments of
the patient. If the patient is hemodynamically unstable, the
patient is at risk for falls. Patients with MWT should be placed
on fall precautions and should be encouraged to call for
assistance if they need to get out of bed. Another major safety
issue the nurse should be aware of is possible ineffective airway
clearance. If the patient is vomiting, there is a great risk for
aspiration. Sedation medication used during endoscopy may
cause ineffective airway clearance and a throat numbing spray
used during the same procedure can increase the risk of
aspiration. The nurse will collaborate with speech therapy to
complete a swallow evaluation before allowing the patient to eat
and drink to avoid aspiration complications. The nurse will
ensure the patient passed the swallow evaluation and place the
patient on aspiration precautions. The nurse will make sure
there is a suction equipment in the patient’s room. The nurse
will put pads on bedrails to prevent bruising and monitor for
any bleeding.
Patient and Family Teaching
Readiness to Learn
It is important to assess the patient’s readiness to learn before
providing them with information. The nurse needs to evaluate
the patients emotional and physical state and decide when the
best time to begin teaching. The nurse should assess what
teaching style will be most beneficial to the patient. Many
factors need to be addressed and taken into consideration with
the assessment such as the patients pain level, education level,
primary language spoken, and what knowledge they have on the
subject already (Flanders, 2018). The nurse will also complete
a cultural assessment to gain an understanding of what the
illness means to the patient. The nurse should also assess
barriers to communication such as hearing and vision.
Teaching Strategies
Once the nurse has established the patient’s language of choice
and combination of learning styles, teaching strategies can be
selected that will be effective for the patient. Learning about

7. something new especially under a stressful situation takes time.
It is always good to try and involve the patient’s family with
teaching sessions. Patient teaching should be done in stages or
segments to enhance absorption of information. It is suggested
that the nurse should not introduce more than three topics at a
time. The patient in the hospital with MWT will be in the
hospital for a couple of days at minimum, affording the nurse
multiple teaching opportunities. The nurse should take notes on
the questions the patient has during teaching and find any
additional resources as needed. It is important to be attentive to
the patient, have uninterrupted time, maintain good eye contact,
and be at eye level with the patient. It is also very important to
acquire the appropriate teaching aids to maximize the education
experience. Example, if the patient does not read well, do not
load him or her up with papers and pamphlets, rather get
creative and utilize websites and videos. If written material is
used, go over it with the patient and them give them time to go
over it themselves. Give the patient a pen and paper and
encourage them to write down any question they may come up
with (Flanders, 2018). The learning environment should also be
free from distractions.
Content
Patient teaching will begin on admission. The patient will be
notified of all options available prior to any actions taking
place. The nurse will complete teaching with the patient and
family on the pertinent subjects specific to the patient’s needs.
For alcohol abuse the nurse will teach the patient about
different treatment options including, cutting back on alcohol
consumption and participation in alcoholics anonymous. The
nurse will teach the patient about smoking cessation and the
different options for quitting. For hypertension the nurse will
teach the patient the importance of taking prescribed medication
and checking blood pressure daily. The nurse will teach the
patient to take the medications even if feeling fine. In regard to
signs and symptoms, the nurse will educate the patient on what
to be aware of. The nurse will impress upon the patient to call

8. the doctor if they notice black, tarry stools, or coffee ground
emesis.
Realistic Complications
Complication 1
The most obvious severe complication associated with MWT
would be, hypovolemic shock related to hemorrhage. This is a
medical emergency where there could be a tear or laceration
large enough to cause a severe bleed. Hypovolemic shock
occurs when there is a significant loss of blood. The body
compensates at first by intense vasocontraction but is then
followed by vasodilation and cardiovascular failure. Noticeable
signs and symptoms of patient deterioration to hypovolemic
shock would be a decrease in blood pressure and an increase in
heart rate. The nurse will perform vitals every four hours as a
preventative measure for hypovolemic shock. The nurse can
anticipate rapid blood transfusions and fluid resuscitation. The
nurse can also anticipate having to administer a vasoactive drip
to maintain adequate perfusing blood pressure. Vasopressin and
Levophed are the two most common vasopressors used to assist
in blood pressure control while trouble shooting the underlying
cause and volume resuscitation (Martin & Schreiber, 2014).
Complication 2
The second complication of MWT is the chance of the patient
extending the bleed or re-bleeding after a treatment. The nurse
must be on high alert for the signs and symptoms of bleeding,
which are decreased blood pressure and increased heart rate.
For early detections of a re-bleed the nurse will do vitals every
four hours. If a re-bleed occurs the nurse will notify the doctor.
At this point the doctor may order an endoscopy or choose to
monitor the patient depending on the severity of the bleed. If
the bleed is extensive it may require a surgical procedure. The
patient may experience dark stools for the next few days
because of the old blood in the intestinal tract, but he or she
should report these finding along with any new bleeding or
bloody emesis immediately. Report the findings to the doctor
and an anticipate a series of hemoglobin and hematocrit

9. laboratory draws approximately every four to six hours.
Monitor the trend and make sure it is going in the right
direction (Rich, 2018).
Complication 3
Another complication that can be seen with a patient suffering
from MWT is dehydration and electrolyte imbalances related to
vomiting and being nothing by mouth (NPO). Frequent
vomiting can cause dehydration which can lead to a number of
electrolyte imbalances, mainly hypokalemia. Hypokalemia if
not treated can lead to a more serious complication like
arrhythmias. Sign and symptoms of hypokalemia are muscle
cramps, spasms, heart palpitations, and difficulty breathing.
Anticipate labs such as a basic metabolic panel will be along
with an electrolyte replacement protocol. Other electrolytes
than can be altered from being NPO are the magnesium and
phosphorus levels. These labs should also be monitored and
replaced per protocol as well. Dehydration can also contribute
to hypotension and symptomatic orthostatic hypotension. The
patient will more than likely be given a fluid bolus along with
maintenance intravenous fluids per the doctors’ orders (Jahraus,
2018). The nurse should anticipate placing the patient on a
heart monitor.
Conclusion
Although a Mallory Weise Tear can have very serious
complications, the majority of them heal on their own. This
ailment can be prevented and with good patient teaching,
hopefully the patient will not have a reoccurrence. The paper
discussed peer-reviewed literature surrounding MWT and the
pathophysiology. Next the paper provided complications that
can arise with a diagnosis of MWT, the warning signs and how
to manage patient care. The paper also covered the nursing
process and treatments for a patient that suffers from MWT.
The final paragraph of this paper covered teachings for the
patient and family on signs and symptoms of MWT and its
complications. While creating this paper this author learned
various techniques to research topics, and how to properly

10. format a paper. The experience afforded the author the
opportunity to practice skilled necessary to complete a
bachelor’s program in nursing.
Nursing Narrative
While performing my assessment on the patient I noticed bloody
sputum in his emesis basin. I asked the patient when this had
happened, he stated “I started coughing up some blood this
morning, it happened twice, it hasn’t happened again”. It is
now 1100, patient stated “it happened around 0730”. I elevated
the head of the bed to a minimum of 30 degrees and notified the
Dr. I have instructed the patient to notify the nurse right away if
it happens again. I also provided information on how to try not
to put any stress on his esophagus. If he needs to cough or
sneeze to try and do so into a pillow. Patient will remain on a
clear liquid diet. I will continue to monitor patient.
MALLORY WEISE TEAR 2
References
Cherednikov, E. F., Kunun, A. A., Cherednikov, E. E., &
Moiseeva, N. S. (2016). The role of etiopathogenetic aspects in
prediction and prevention of discontinuous-hemorrhagic
(Mallory-Weiss) syndrome. EPMA Journal, 7.
http://dx.doi.org/10.1186/s13167-016-0056-4
Flanders, S. A. (2018). Effective patient education: Evidence
and common sense. Medsurg Nursing, 27(1), 55-58. Retrieved
from
https://search.proquest.com/nahs/docview/2006753584/fulltext/
BE98929276D04CCEPQ/1?accountid=100141

11. Hyun-Soo, K. (2015, March ). Endoscopic management of
Mallory-Weiss tearing. Clinical Endoscopy, 48(2), 102-105.
http://dx.doi.org/10.5946/ce.2015.48.2.102
Jahraus, J. (2018). Medical complications of eating disorders.
Psychiatric Annals, 48(10), 463-467.
http://dx.doi.org/10.3928/00485713-20180912-04
Martin, D. T., & Schreiber, M. A. (2014, December ). Modern
resuscitation of hemorrhagic shock: What is on the horizon? .
European Journal of Trauma and Emergency Surgery, 40(6),
641-656. http://dx.doi.org/10.1007/s00068-014-0416-5
Nojkov, B., & Cappell, M. S. (2016, Jan 7). Distinctive aspects
of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss
syndrome in patients with advanced alcoholic liver disease or
cirrhosis. World Journal of Gastroenterolgy, 22(1), 446-466.
http://dx.doi.org/10.3748/2Fwjg.v22.i1.446
Rich, K. (2018, June). Overview of Mallory-Weiss syndrome.
Journal of Vascular Nursing, 36(2), 91-93.
http://dx.doi.org/10.1016/j.jvn.2018.04.001