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).
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 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 Helpance 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 Assessment before allowing the patient to eat and drink to avoid aspiration complications. The nurse will ensure the patient passed the swallow Assessment 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 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 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 Help 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 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 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
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
