Department: ACTION STAT
Mr. D, 47, ARRIVES in the ED complaining of heaving and forceful vomiting with blood for the past 3hours. Although the vomiting stopped, he says he feels like passing out when he stands up. You assess Mr. D and find that he's pale and diaphoretic. His vital signs are temperature, 99o F (37.2o C); pulse, 120 and regular; respirations, 28; BP, 94/60; and SpO2, 93% on room air.
You position Mr. D supine with the head of the bed flat, provide supplemental oxygen via non-rebreather mask, place him on a cardiac monitor, which shows sinus tachycardia, and obtain peripheral venous access. Abdominal assessment reveals a soft, nondistended abdomen with hyperactive bowel sounds. Peripheral pulses are 2+ and capillary refill time is less than 3 seconds. After your assessment, Mr. D vomits 250 mL of bright red blood.
What's the situation?
Mr. D has a history of dyslipidemia and takes simvastatin. He says he was celebrating a friend's birthday with "quite a few" shots of alcohol and several servings of picnic food. He tells you he drinks at least two beers a couple times a week.
What's your assessment?
Because of Mr. D's history and presenting signs and symptoms, you suspect Mallory-Weiss syndrome, also known as Mallory-Weiss laceration or Mallory-Weiss tear. The tear is usually related to a sudden increase in intra-abdominal pressure from precipitating factors including vomiting, retching, straining, and coughing. It's strongly correlated with severe alcohol ingestion. The tear is often located in the esophagogastric junction, often within a hiatal hernia. Because this area is highly vascular, severe bleeding is possible. In most cases, bleeding stops spontaneously, although many patients need blood transfusions.
What must be done immediately?
Notify the ED physician. As prescribed, infuse 0.9% sodium chloride for fluid resuscitation. Obtain blood specimens and include testing for type and crossmatch.
After 10 minutes, Mr. D's clinical status is deteriorating. His BP is now 70/50 mm Hg. Blood study results include hemoglobin 9.1 g/dL (normal, 13.5 to 18); hematocrit 28% (normal, 40% to 50%); and an abnormal coagulation profile.
Mr. D is transferred to the ICU and receives an emergent blood transfusion. A stat esophagogastroduodenoscopy shows a Mallory-Weiss tear. Epinephrine is injected into the area and hemostasis is achieved.
What must be done later?
Mr. D has no further bleeding; his vital signs remain stable. He's transferred to a regular room and then discharged home to follow up with his healthcare provider within the next few days or sooner if he begins to feel worse. You encourage alcohol cessation.
. Cuffari C. Mallory-Weiss syndrome.
. Guelrud M. Mallory-Weiss syndrome.
Kaplow R, Hardin S. Critical Care Nursing: Synergy for Optimal Outcomes
. Boston, MA: Jones and Bartlett; 2007.
Sole ML, Klein DG, Moseley MJ. Introduction to Critical Care Nursing
. 5th ed. St. Louis, MO: Sanders Elsevier; 2009.
. Wong Kee Song L. Mallory-Weiss tear.