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.

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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 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 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 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 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).

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