Mallory-Weiss syndrome is a tear or laceration, usually singular and longitudinal, in the mucosa at the junction of the distal esophagus and proximal stomach. Esophageal lacerations account for between 5% and 10% of upper gastrointestinal (GI) bleeding episodes. Approximately 60% of the tears involve the cardia, the upper opening of the stomach that connects with the esophagus. Another 15% involve the terminal esophagus, and 25% involve the region across the epigastric junction. In a small percentage of patients, the tear leads to upper GI bleeding. Most episodes of bleeding stop spontaneously, but some patients require medical intervention. If bleeding is excessive, hypovolemia and shock may result. Esophageal rupture (Boerhaave syndrome) is rare but catastrophic when it does occur. If esophageal perforation occurs, the patient may develop abscesses or sepsis.
The most common cause of Mallory-Weiss syndrome is failure of the upper esophageal sphincter to relax during prolonged vomiting. This poor sphincter control is more likely to occur after excessive intake of alcohol. Any event that increases intra-abdominal pressure can also lead to an esophageal tear, such as persistent forceful coughing, trauma, seizure, pushing during childbirth, or a hiatal hernia. Other factors that may predispose a person to Mallory-Weiss syndrome are esophagitis, gastritis, and atrophic gastric mucosa.
Nursing care plan assessment and physical examination
The patient may report a history of retching and vomiting, followed by vomiting bright red blood. Ask the patient about the appearance of the vomitus. Hematemesis has a “coffee- ground” appearance if it is of gastric origin and is often a sign of brisk bleeding, usually from an arterial source or esophageal varices. Ask about passage of blood with bowel movements, either a few hours to several days after vomiting. Although vomiting and retching before the onset of bleeding can be indicative of a Mallory-Weiss tear, some patients with Mallory-Weiss syndrome do not present with such a history. Inquire about weakness, fatigue, and dizziness, any and all of which can result with chronic blood loss. Ask about a history of alcoholism, hiatal hernia, seizures, or a recent severe cough.
Inspect the patient’s nasopharynx to rule out the nose and throat as the source of bleeding. Assess the patient for evidence of trauma to the head, chest, and abdomen as well. Note that manifestations of GI bleeding depend on the source of bleeding, the rate of bleeding, and the underlying or coexisting diseases. Patients with massive bleeding have the clinical signs of shock, such as a heart rate greater than 110 beats per minute, an orthostatic blood pressure drop of 16 mm Hg or more, restlessness, decreased urine output, and delayed capillary refill.
The sudden admission to an acute care facility for GI bleeding is stressful and upsetting. Assess the patient’s anxiety level, along with his or her understanding of the treatment and intervention plan. Because Mallory-Weiss syndrome is associated with alcohol use and abuse, determine if the patient is a problem drinker and assess the family’s and significant others’ responses to the patient’s drinking.
Nursing care plan primary nursing diagnosis: Airway clearance, ineffective, related to aspiration of blood.
Nursing care plan intervention and treatment plan
Bleeding often subsides spontaneously, but if it does not, a Sengstaken-Blakemore or Minnesota tube is inserted to provide pressure at the source of bleeding by using a balloon tamponade. For continued bleeding, a nasogastric tube may be placed and connected to continuous low suction with periodic lavages. Intra-arterial infusion of vasopressin or therapeutic embolization into the left gastric artery during arteriography has also been shown to be effective in controlling bleeding in some patients. Other strategies to halt bleeding include endoscopy with electrocoagulation for hemostasis or transcatheter embolization with an autologous blood clot or artificial material, such as a gelatin sponge. On rare occasions, the patient may require surgery to suture the laceration.
If the patient has excessive blood loss, institute strategies to support the circulation. To stabilize the circulation and replace vascular volume, place a large-bore (14- to 18-gauge) intravenous catheter and maintain replacement fluids such as 0.9% sodium chloride and blood component therapy as prescribed. With continued or massive bleeding, the patient may be supported with blood transfusions and admitted to an intensive care unit for close observation.
A major cause of morbidity and mortality in patients with active GI bleeding is aspiration of blood with subsequent respiratory compromise, which is seen in patients with inadequate gag reflexes or those who are unconscious or obtunded. Constant surveillance to ensure a patent airway is essential. Check every 8 hours for the presence of a gag reflex. Maintain the head of the bed in a semi-Fowler position unless contraindicated. If the patient needs to be positioned with the head of the bed flat, place the patient in a side-lying position.
Encourage bedrest and reduced physical activity to limit oxygen consumption. Plan care around frequent rest periods, scheduling procedures so the patient does not overtire. Avoid the presence of noxious stimuli that may be nauseating. Support nutrition by eliminating foods and fluids that cause gastroesophageal discomfort. Encourage the patient to avoid caffeinated beverages, alcohol, carbonated drinks, and extremely hot or cold food or fluids. Help the patient understand the treatments and procedures. Provide information that is consistent with the patient’s educational level and which takes into account the patient’s state of anxiety.
Nursing care plan discharge and home health care guidelines
Teach the patient to avoid foods and fluids that cause discomfort or irritation. Determine the patient’s understanding of any prescribed medications, including dosage, route, action or effect, and side effects. Review signs and symptoms of recurrent bleeding and the need to seek immediate medical care. Provide a phone number for the patient to use if complications develop.
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