List of Abbreviations
H2 blockers – histamine H2 receptor antagonists (ATC code: A02BA)
H. pylori – Helicobacter pylori
BP – blood pressure
APC – argon plasma coagulation
UAGT – upper alimentary gastrointestinal tract
EVvar – esophageal varices
GV – globular volume
CI – confidence interval
Du – duodenum
GIT – gastrointestinal bleeding
GI – gastrointestinal tract
IMV – invasive mechanical ventilation
PPIs – proton pump inhibitors (ATC code: A02BC)
CT – computed tomography
INR – international normalized ratio
HC – healthcare organization
NSAIDs – non-steroidal anti-inflammatory and antirheumatic drugs (ATC code: M01A)
RR – relative risk
ICU – intensive care unit
BV – blood volume
OR – odds ratio
PU – perforated peptic ulcer
MWS – Mallory-Weiss syndrome
ESR – erythrocyte sedimentation rate
TAE – transcatheter arterial embolization
LCE – level of confidence of evidence
US – ultrasound examination
GRS – grade of recommendation strength
NNT – number needed to treat
HR – heart rate
EGD – esophagogastroduodenoscopy
EVS – endovascular vessel embolization
PUD – peptic ulcer disease
UGIB – upper gastrointestinal bleeding
Terms and Definitions
Mallory-Weiss syndrome is the formation of acute linear tears in the mucosa of the abdominal esophagus and the cardiac region of the stomach during recurrent vomiting, accompanied by bleeding.
Previous (resolved) esophagogastric bleeding is a clinical term reflecting the objectively confirmed fact that a patient has experienced intraluminal bleeding from a tear in the esophagus and/or stomach. The term is most commonly used to characterize bleeding that has spontaneously stopped by the time of diagnosis.
Ongoing esophagogastric bleeding is bleeding from tears in the wall of the esophagus and/or stomach, characterized by the flow of blood from the tear site observed during endoscopic examination or surgical intervention. A sign of ongoing bleeding during an endovascular intervention is the extravasation of contrast medium beyond the vascular bed.
Recurrent esophagogastric bleeding (recurrent esophagogastric bleeding) – the resumption of bleeding from the same tear in the esophageal and/or gastric wall that served as the source of primary bleeding, following its spontaneous or endoscopic cessation, or after surgical intervention. In most cases, recurrent bleeding develops while the patient is hospitalized.
Surgical intervention is an invasive procedure that may be used for diagnostic purposes and/or as a method of treating diseases.
Surgical treatment – a method of treating diseases by dividing and uniting tissues during a surgical operation.
Endovascular treatment is a surgical intervention performed on blood vessels via a percutaneous approach under image guidance.
Eradication is treatment aimed at eliminating Helicobacter pylori (H. pylori) infection.
First-line eradication regimen is the H. pylori eradication regimen prescribed as the first choice.
Second-line eradication regimen is an eradication regimen prescribed when the first-line H. pylori regimen is ineffective.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Mallory-Weiss syndrome is the formation of acute linear tears in the mucosa of the abdominal esophagus and the cardiac region of the stomach during recurrent vomiting, accompanied by bleeding.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The cause of the tears is typically repetitive vomiting accompanied by increased intragastric or intra-abdominal pressure, as well as cardioesophageal spasm.
Main etiological factors:
Vomiting:
The most frequent and common factor. Vomiting, especially severe and prolonged, can be caused by various factors, including alcohol, poisoning, digestive system diseases, etc.
Increased intra-abdominal pressure:
In addition to vomiting, other conditions leading to increased intra-abdominal pressure can also contribute to the development of Mallory-Weiss syndrome. This may be associated with severe coughing, heavy physical exertion, abdominal trauma, childbirth, etc.
Drugs:
Certain medications, such as acetylsalicylic acid**, can cause irritation of the gastric mucosa and, in the presence of other risk factors, contribute to the development of tears.
Upper GI tract diseases:
Chronic diseases of the upper gastrointestinal tract (gastritis, esophageal ulcers), hiatal hernia, and portal hypertension can also increase the risk of developing the syndrome.
Iatrogenic factors:
Damage to the mucosa during endoscopic procedures, insertion of a nasogastric tube, or cardiopulmonary resuscitation can also cause tears.
Risk factors:
Alcoholism and bulimia:
These conditions are often associated with frequent and severe vomiting, which increases the risk of developing the syndrome.
Gastroesophageal reflux disease (GERD):
Dysfunction of the lower esophageal sphincter can contribute to increased intra-abdominal pressure and the development of tears.
Pregnancy:
During pregnancy, there may be an increased risk of vomiting and changes in esophageal function, which increases the likelihood of developing the syndrome.
Pathogenesis:
The primary mechanism causing tears of the esophagogastric junction mucosa is vomiting. M. Atkinson et al. (1962) established that during vomiting, gastric pressure in patients reached 120–150 mm Hg, and occasionally rose to 200 mm Hg [220]. During strained vomiting movements, coordination between the "locking" function of the cardia and pylorus and the strong antiperistaltic contractions of the stomach is disrupted. In this case, intragastric pressure rises sharply during vomiting, which leads to a rupture of the gastroesophageal junction wall. The pathogenesis of this disease remains incompletely understood to this day.
1.3 Epidemiology of the Disease or Condition
Mallory-Weiss tear is a rare cause of upper GI bleeding, accounting for approximately 5% of all cases. It occurs more frequently in men. This syndrome predominates among patients aged 40–50 years, but can occur at other ages as well. The incidence is 7.5 cases per 100,000 population, and in-hospital mortality is 2.7%.
1.4 Features of Coding the Disease or Condition
K22.6 Gastroesophageal laceration-hemorrhage syndrome
1.5 Classification of the disease or condition
There is no universally accepted classification of MWS.
The following stages of Mallory-Weiss syndrome are distinguished:
Stage I – rupture (fissures) of the mucosa of the lower third of the esophagus and cardioesophageal junction;
Stage II – rupture (fissures) of the mucosa and submucosal layer;
Stage III – rupture (fissures) involving the circular muscle layer. The rupture zone does not spasm or close; intense bleeding occurs;
Stage IV – rupture of all layers of the esophagus and cardioesophageal junction, accompanied by peritonitis, mediastinitis, and pneumothorax.
Endoscopic findings in MWS:
According to the severity of bleeding, the most widely used classification in our country is the A.I. Gorbashko 1982 classification (Appendix G1) [16], which uses a 3-grade scale distinguishing mild, moderate, and severe bleeding, taking into account both the volume of blood loss and the patient's general condition. The American College of Surgeons blood loss severity scale (Appendix G2) distinguishes 4 classes (degrees) of blood loss: mild, moderate, severe, and massive [85].
1.6 Clinical presentation of the disease or condition
The clinical presentation of Mallory-Weiss syndrome is typically characterized by vomiting blood (hematemesis): it can range from small streaks of blood to massive hemorrhage. The color of the blood can vary from bright red to dark, depending on how long the blood has been in the digestive tract.
Mallory-Weiss syndrome frequently develops after episodes of vomiting, retching, severe coughing, hiccups, and other factors that can increase intra-abdominal pressure and provoke mucosal tears.
The clinical manifestations of esophagogastric bleeding in MWS can be divided into two groups of symptoms:
General signs of blood loss (weakness, dizziness, loss of consciousness, cold clammy sweat, decreased blood pressure, tachycardia) and
Symptoms caused by the entry of blood into the gastrointestinal lumen, which include hematemesis and melena. Blood loss of 100 ml can lead to black, but formed stool. "True" melena (tarry, i.e., black and liquid stools) in an adult occurs with a blood loss volume of about 500 ml. Rapid and massive blood loss into the intestinal lumen may manifest as hematochezia – the passage of blood with clots through the rectum.
Objective examination reveals: altered patient behavior (anxiety, fright or apathy, drowsiness; in severe bleeding – psychomotor agitation, delirium, hallucinations); pallor of the skin; pulse changes (rapid, low volume); blood pressure tends to decrease depending on the severity of blood loss; respiration is rapid. Digital rectal examination, which is mandatory when gastrointestinal bleeding is suspected, helps detect changes in stool color.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for diagnosing the disease/condition:
The diagnosis of MWS is established based on:
1) anamnesis data (characteristic complaints, previous history of peptic ulcer disease);
2) physical examination;
3) instrumental examination (detection of an esophageal and/or gastric tear during endoscopic examination (esophagogastroduodenoscopy)).
The diagnostic program for MWS should: 1) establish the fact of acute bleeding into the upper GI lumen; 2) identify the source of bleeding; 3) determine the severity of blood loss. In life-threatening bleeding, diagnostic examinations must be performed concurrently with urgent therapeutic measures.
Diagnostic criteria:
The diagnosis of Mallory-Weiss syndrome (MWS) is established based on a combination of general clinical signs of blood loss, signs of gastrointestinal bleeding, medical history and laboratory data, confirmed by EGD results. Upon admission to the hospital, the patient must be immediately examined by a surgeon and urgent laboratory diagnostics performed.
For patients with MWS, to determine the severity of blood loss, it is recommended to use the A.I. Gorbashko classification, 1982 [16] (Appendix G1), and the ACS (American College of Surgeons) scoring scale [1] (Appendix G2) [16,19].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
For patients with MWS, to determine the severity of blood loss, it is recommended to use the Shock Index (Appendix G6) [221,222].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
In patients with MWS, it is recommended to assess the risk of bleeding recurrence based on a combination of clinical and endoscopic data [21,22].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: the criteria for high risk of bleeding recurrence in MWS include clinical (history of collapse, severe blood loss, severe concomitant pathology) and laboratory signs reflecting mainly the intensity of bleeding, as well as endoscopic signs (deep tears, ongoing bleeding at the time of endoscopy) [11,15,21]. To assess the risk of bleeding recurrence and determine further management tactics, the AIMS65 score (Appendix G3), Glasgow-Blatchford Bleeding Score (Appendix G4) and the repeatedly validated Rockall score (Appendix G5) can be used.
2.1 Complaints and Anamnesis
Complaints and medical history data characteristic of patients with MWS are specified in subsection 1.6.
In a patient with signs of upper GI bleeding, it is recommended to analyze complaints, history of present illness, and personal medical history at the stage of hospital admission, but this should not lead to a delay in emergency diagnostic and therapeutic measures [12,14,19,21].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: it is important to find out how long ago the bleeding started; whether pre-syncope or loss of consciousness was noted; whether there were single or repeated episodes of hematemesis, the volume and nature of the vomitus (bright red or dark blood, clots, “coffee-ground” contents); and the frequency of melena episodes.
It is necessary to identify conditions that may cause acute bleeding in MWS: severe comorbidities (CHD, myocardial infarction, heart failure, cerebrovascular accident, renal and hepatic failure, oncological and hematological diseases, alcoholism); treatment with antithrombotic agents (ATX code: B01A).
Upon admission to the emergency department of a patient with suspected MWS, an examination by a surgeon is recommended to rule out or confirm this diagnosis and determine further management tactics [108,110].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
2.2 Physical Examination
Physical examination data characteristic of patients with MWS are given in subsection 1.6.
A patient with signs of upper GI bleeding is recommended to undergo an examination upon admission, including the assessment of all major body systems and a digital rectal examination (A01.19.004) [12,13,14,223].
GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Comments: objective examination data combined with complaints and medical history, already at the stage of patient admission, make it possible to judge the severity and presumed source of bleeding, as well as concomitant diseases. Confused consciousness, severe pallor of the skin and conjunctivae, rapid pulse of low volume and tension, decreased blood pressure and pulse pressure, the presence of a large amount of blood and clots in the stomach, and black liquid or blood-tinged contents upon rectal examination are signs of acute massive bleeding.
Inspection of the skin and visible mucous membranes may reveal subicteric or yellowish discoloration, spider angiomas, and dilated subcutaneous veins on the anterolateral abdominal wall, which typically occurs in liver diseases; intradermal or subcutaneous hemorrhages and multiple telangiectاسises in vascular diseases and blood coagulation disorders. Clinical observations have verified that a blood pressure below 100 mm Hg and a heart rate exceeding 100 beats per minute in a patient with normal baseline pressure correspond to a blood loss of about 20% of the circulating blood volume (CBV). Percussion in diseases of the esophagus, stomach, and duodenum (A01.16.004) and palpation in diseases of the esophagus, stomach, and duodenum (A01.16.003) in a number of cases allow for the detection of a gastric tumor, hepatosplenomegaly, signs of ascites, and enlarged dense lymph nodes. The patient's examination must be completed with a digital rectal examination and, if necessary, gastric probing. The objective data obtained in this process, regardless of the presence or absence of anamnestic indications of hematemesis and melena, are important signs supporting the clinical diagnosis.
2.3 Laboratory Diagnostics
There are no specific laboratory signs for MWS. Laboratory tests in patients with bleeding in MWS generally include on an emergency basis: determination of main blood groups by the AB0 system; determination of the D antigen of the Rh system (Rh factor), determination of a subgroup and other minor blood groups A-1, A-2, D, Cc, E, Kell, Duffy; complete blood count; blood sodium level, blood potassium level, blood chloride level, acid-base status and blood gases, blood osmolarity (osmolality); blood urea nitrogen, blood creatinine, prothrombin time in blood or plasma, international normalized ratio (INR), blood fibrinogen; blood glucose, total blood protein, blood albumin, total blood bilirubin, alanine aminotransferase activity, aspartate aminotransferase activity) [12,14,19,21].
A drop in hemoglobin levels, a decrease in red blood cell count, and a drop in hematocrit undoubtedly guide the assessment of the severity of blood loss. However, in the first hours from the onset of acute bleeding, even if it is brisk, hemodilution does not have time to develop, and therefore all these indicators may change insignificantly. In addition to anemia resulting from acute blood loss and the action of blood spilled into the lumen of the digestive tract, there is often moderate leukocytosis and hyperbilirubinemia (due to the indirect fraction), and an elevated urea level with normal creatinine values, which is associated with the syndrome of blood reabsorption in the intestine.
Investigation of CBV and its components using dyes and radioisotopes is currently practically not used. The severity of the patient's condition and their individual reactions to the sustained blood loss are quite accurately characterized by a number of central hemodynamics indicators, oxygen transport, as well as metabolic disorders (blood urea, electrolytes, acid-base status, plasma osmolarity, etc.).
Blood loss, especially severe, can lead to hypocoagulation with prolonged blood clotting time, decreased prothrombin and fibrinogen levels up to the development of acute fibrinolysis.
2.4 Instrumental Diagnostics
All patients with suspected bleeding in MWS, in the absence of contraindications, are recommended to undergo esophagogastroduodenoscopy (EGD) (A.03.16.001) to confirm the diagnosis [2].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: endoscopic examination confirms the presence of a rupture of the esophageal and/or gastric wall, clarifies its localization, shape, size, depth, presence of hiatal hernia and reflux esophagitis.
Emergency endoscopic examination – esophagogastroduodenoscopy (EGD) (A03.16.001) is recommended to be performed in all patients with acute upper gastrointestinal bleeding, under procedural sedation with monitoring of the patient's vital signs during anesthesia (B03.003.006), concurrently with infusion-transfusion therapy [28].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: EGD must be performed within 2 hours from the moment of the patient's hospitalization. The endoscopic method is of decisive importance for establishing the source and nature of bleeding, assessing the necessity and feasibility of endoscopic hemostasis/prophylaxis, as well as for predicting the risk of bleeding recurrence.
Before performing EGD in patients with suspected gastroesophageal bleeding, it is recommended to perform gastric sounding (A11.16.009) followed by gastric lavage (A11.16.008) to prepare for the procedure [19,21,23].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
In a number of cases, when it is impossible to adequately lavage and evacuate the gastric contents during gastric intubation and lavage, it is recommended to use #Erythromycin (ATC code: J01FA01) in parenteral form (200 mg single dose) to stimulate gastric motility [224].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: The European Society of Gastrointestinal Endoscopy (ESGE) also considers it acceptable for this purpose to use gastrointestinal motility stimulants (ATC code: A03F) or parenteral #Erythromycin (ATC code: J01FA01) (200 mg single dose) [224]. The European Society of Gastrointestinal Endoscopy (ESGE) also recommends performing tracheal intubation prior to upper GI endoscopy in patients with ongoing active bloody vomiting, encephalopathy, or agitation, in order to protect the patient's airway from potential aspiration of gastric contents [12,224].
If a large amount of blood, clots, or food masses are detected in the gastric lumen during upper GI endoscopy, it is recommended to withdraw the flexible medical endoscope for examination of the gastrointestinal tract and evacuate the contents via a gastric tube [19,21,23].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments. Biopsy of the edges of esophageal and gastric tears (endoscopic esophageal biopsy) is in most cases impractical, may be dangerous in terms of re-bleeding, or technically difficult.
2.5 Other Procedures
In all patients with Mallory-Weiss syndrome, in order to determine indications for eradication therapy, it is recommended to test for H. pylori infection using a Helicobacter pylori 13C-urea breath test or stool antigen test, and if upper GI endoscopy is performed simultaneously, using a rapid urease test (device for express diagnostics of helicobacteriosis based on biopsy specimen urease activity (in vitro)) [30].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: if there is no technical capability for initial diagnosis of H. pylori infection in the inpatient setting, performing it in an outpatient setting is acceptable. In accordance with the recommendations of the Maastricht VI Consensus Conference (2022), the most optimal tests for the initial diagnosis of H. pylori infection are the 13C-urea breath test for Helicobacter pylori and the H. pylori stool antigen test. Thus, according to the latest Cochrane review and meta-analysis, the sensitivity of the 13C-urea breath test is 94% (95% CI: 0.89 - 0.97), and that of the Helicobacter pylori stool antigen test is 83% (95% CI: 0.73 - 0.90) at a fixed specificity of 90% [30].
If patients undergo upper GI endoscopy simultaneously, the rapid urease test (device for express diagnostics of helicobacteriosis based on biopsy specimen urease activity (in vitro)) can be used as the primary diagnostic method. When using endoscopic diagnostic methods for H. pylori, at least 2 biopsy specimens from the gastric body and 1 biopsy specimen from the antrum are taken. The serological method for detecting antibodies to H. pylori (determination of antibodies to Helicobacter pylori in blood) can be used for the initial diagnosis of H. pylori infection, but only if the detected antibodies belong to the IgG class. The microbiological (bacteriological) method (microbiological (cultural) examination of gastric mucosa biopsy specimens for Helicobacter pylori with determination of sensitivity to systemic antibacterial drugs) is currently used to determine the individual sensitivity of H. pylori to systemic antibacterial drugs in cases of treatment failure.
In all patients with Mallory-Weiss syndrome, it is recommended to consider monitoring H. pylori eradication to determine the further treatment program [32].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: to check eradication 4–6 weeks after completion of eradication therapy, it is advisable to use the 13C-H. pylori urea breath test (A07.16.006) and/or Helicobacter pylori stool antigen test (A26.19.020). Proton pump inhibitors must be discontinued 2 weeks before the planned follow-up test. A negative result must be confirmed by two diagnostic methods [31,32].
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
Treatment of Mallory-Weiss syndrome should be comprehensive and include not only the prescription of medications, but also a wide range of various measures: diet therapy, smoking cessation and avoidance of alcohol abuse, discontinuation of ulcerogenic drugs, normalization of work and rest regimens, and sanatorium-resort treatment.
3.1 Diet therapy
In all patients with Mallory-Weiss syndrome, in order to accelerate the healing of tears, it is recommended to prescribe diet therapy [34].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: the basic principles of dietary nutrition for patients with Mallory-Weiss syndrome, developed many years ago, remain relevant today. Recommendations for frequent (5–6 times a day), fractional meals adhering to the rule "six small meals are better than three large ones," along with mechanical, thermal, and chemical sparing, remain in effect. The diet should exclude foods that irritate the gastric mucosa and stimulate hydrochloric acid secretion: strong meat and fish broths, fried and spiced foods, smoked meats and canned goods, condiments and spices (onions, garlic, pepper, mustard), pickles and marinades, carbonated fruit drinks, beer, dry white wine, champagne, coffee, and citrus fruits.
Preference should be given to foods with pronounced buffering properties (i.e., the ability to bind and neutralize hydrochloric acid). These include meat and fish (boiled or steamed), eggs, milk, and dairy products. Pasta, stale white bread, dry sponge cake, and dry biscuits, as well as milk and vegetarian soups, are also permitted. Vegetables (potatoes, carrots, zucchini, cauliflower) can be prepared stewed or in the form of purees and steamed soufflés. Porridges, sweet berry kissels, mousses, jellies, raw grated and baked apples, cocoa with milk, and weak tea can be included in the diet.
One should also remember such simple yet important recommendations as the need to eat in a calm atmosphere, without rushing, while sitting, and chewing food thoroughly. This promotes better impregnation of food with saliva, the buffering capacity of which is quite pronounced.
3.2 Conservative treatment
Management of patients with Mallory-Weiss syndrome (as in all cases of upper gastrointestinal bleeding) at the pre-hospital stage and upon admission to the hospital
In all patients with signs of upper GI bleeding, it is recommended to immediately initiate intensive care at the pre-hospital stage and/or upon admission to the hospital [6].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
In all patients with clinical symptoms of bleeding in Mallory-Weiss syndrome, it is recommended to administer parenteral proton pump inhibitors (A02BC) upon hospital admission [13,19,23,81,102].
GGR BLOE 1Grade of Recommendation B (Level of Evidence – 1)
Comments: administration of proton pump inhibitors at the pre-hospital stage and prior to initial upper GI endoscopy reduces the need for endoscopic hemostasis, but should not cause a delay in endoscopy.
It is recommended to stratify patients upon hospital admission according to severity and probability of death to address the issue of hospitalization / transfer of patients with severe bleeding to the ICU [19].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: for the purpose of stratifying patients with Mallory-Weiss syndrome by severity of blood loss and probability of death the following scales can be used: Glasgow-Blatchford [16,20] (Appendix G4), AIMC65 (Appendix G3), Shock Index (> 0.8) [20] (Appendix G6), ACS score (Appendix G2).
Management of patients with massive blood loss
The main objectives of intensive care are to ensure adequate cellular oxygen delivery and consumption, and to correct hemostasis.
In patients with Mallory-Weiss syndrome presenting with hemodynamic instability, replenishment of circulating blood volume is recommended to begin with the administration of balanced salt solutions (B05CB) [28].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
In patients with Mallory-Weiss syndrome presenting with non-massive blood loss, it is recommended to perform restrictive infusion-transfusion therapy [27].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: in patients with Mallory-Weiss syndrome, it is necessary to achieve target perfusion adequacy parameters after "surgical" hemostasis is performed. Liberal infusion-transfusion therapy and early achievement of hemodynamic target parameters (prior to surgical hemostasis) can lead to hemodilution and increased perfusion pressure, which entails an increase in blood loss [83,84]. In certain cases, in patients with a burdened comorbid background, when it is necessary to ensure a personalized approach to infusion therapy, it is permissible to use volemic status assessment methods such as echocardiography (assessment of cardiac output, stroke volume, blood flow velocity) and transpulmonary thermodilution [219].
For patients with Mallory-Weiss syndrome, blood transfusion is recommended when the hemoglobin level is less than 70 g/L; for patients with cardiovascular diseases, the threshold for starting a blood transfusion may be higher at 90 g/L [13,27,28,235].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
For patients with Mallory-Weiss syndrome, fresh frozen plasma transfusion is recommended in the presence of hypocoagulation and ongoing bleeding or a high risk of its recurrence [235].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
In patients with Mallory-Weiss syndrome and massive blood loss, it is recommended to maintain a platelet count above 50 × 109/L [27].
Level of Evidence CGrade of Recommendation 5Level of Evidence C (reliability of evidence – 5)
In some patients with Mallory-Weiss syndrome (showing signs of severe hypoperfusion), the use of norepinephrine** (ATC code: C01CA03) and epinephrine** (ATC code: C01CA24) is recommended to maintain adequate perfusion pressure [27,28,225,226].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
The use of norepinephrine** (ATC code: C01CA03) and epinephrine** (ATC code: C01CA24) may also be recommended when myocardial contractility decreases, in order to improve it [27,28,225,226].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: the criteria for restoring adequate perfusion are: skin condition (mottling, capillary refill time, temperature); level of consciousness; urine output; normalization of acid-base balance and lactate; and achievement of target hemodynamic parameters [13,16].
The criteria for adequate transfusion therapy are: absence of pathological bleeding (provided "surgical" hemostasis has been performed); normalization of hemostasis based on global coagulological tests and/or viscoelastic hemostasis testing (e.g., thromboelastography) [16,27,28].
3.3. Endoscopic treatment
In patients with Mallory-Weiss syndrome with ongoing bleeding from esophageal and/or gastric tears, it is recommended to perform hemostasis (A16.12.020 Stopping bleeding from a peripheral vessel) via an endoscope (flexible, reusable videogastroscope) [13,19,23,31].
GGR BLOE 1Grade of Recommendation B (Level of Evidence – 1)
Comments: in case of stopped bleeding, removal of the blood clot is possible using targeted washing [13,19,23,31].
In patients with Mallory-Weiss syndrome with stopped bleeding, routine endoscopic prophylaxis of recurrent bleeding is not recommended [13,19,23,31].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: in such cases, ensuring adequate medical prophylaxis for recurrent bleeding is essential. Endoscopic hemostasis (prevention of recurrence) must be performed within 2 hours of the patient's hospital admission. In patients with Mallory-Weiss syndrome, for endoscopic hemostasis of bleeding from tears and prevention of its recurrence, it is advisable to use injection hemostasis combined with thermal methods (diathermocoagulation, argon plasma coagulation (A22.30.033.001)) or clipping (Stopping bleeding from a peripheral vessel; Endoscopic stopping of bleeding from a peripheral vessel using electrocoagulation; Endoscopic stopping of bleeding using thermocoagulation, Endoscopic clipping of a bleeding vessel, Argon plasma coagulation of a bleeding vessel) [13,14,19,23]. Injection hemostasis as monotherapy does not provide proper efficacy and should only be used in combination with other methods of endoscopic hemostasis. Other local endoscopic hemostasis methods may be used as an adjunct to combined endoscopic hemostasis [13,14,19,23,31].
In patients with Mallory-Weiss syndrome, a repeated control endoscopic examination/intervention is recommended if the initial examination was incomplete or in case of recurrent bleeding [86].
GGR BLOE 1Grade of Recommendation B (Level of Evidence – 1)
Comments: routine performance of a control endoscopic examination in all patients with Mallory-Weiss syndrome is impractical. If the initial examination was incomplete, a repeat endoscopic examination is recommended within the first few hours after the initial EGD [87,227].
Diet and pharmacotherapy for patients with Mallory-Weiss syndrome complicated by bleeding:
For patients with a high risk of recurrent bleeding after its endoscopic cessation/prophylaxis, administration of PPIs (e.g., esomeprazole** at a dose of 80 mg IV bolus followed by a continuous infusion of 8 mg per hour for 72 hours) is recommended immediately after endoscopic hemostasis to prevent bleeding recurrence [13,19,23,81].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: in patients with Mallory-Weiss syndrome who initially received parenteral PPIs, switching to oral formulations is performed 72 hours after the start of therapy [13,19,23]. In patients with Mallory-Weiss syndrome with a low risk of bleeding recurrence, parenteral administration of PPIs is advisable for 72 hours following endoscopy, followed by a transition to oral formulations until discharge from the hospital and subsequently until complete healing of the tear—the source of the prior bleeding [13,19,23].
For patients with a low risk of bleeding recurrence, switching to enteral nutrition is possible within the first few hours after the completion of the endoscopic intervention [13,19,23]. Patients with a high risk of recurrent bleeding are permitted to drink and consume liquids no earlier than 24 hours after hemostasis is achieved [228,229].
All patients with Mallory-Weiss syndrome confirmed to have Hp infection are recommended to undergo eradication therapy with confirmation of successful eradication [2].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: eradication therapy is initiated after patients are switched to oral PPIs [161]. Successful eradication significantly reduces the risk of recurrent bleeding [162,166].
3.4. Endovascular treatment
For patients with recurrent Mallory-Weiss bleeding resistant to endoscopic and medical hemostasis, it is recommended to consider transcatheter arterial embolization of gastric vessels (A16.12.051) as an alternative to surgical treatment [13,19,89-92].
GCR CLoE 3Grade of Recommendation C (Level of Evidence – 3)
3.5 Surgical treatment
For patients with ongoing or recurrent bleeding when endoscopic hemostasis is ineffective (or impossible), surgical treatment is recommended [13,19,23].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: alternatives to surgical intervention may include the placement of a tamponade tube (e.g., esophageal-gastric rubber tamponade tube) or endovascular interventions (transcatheter vascular embolization using adhesive agents, transcatheter vascular embolization using microemboloids). The scope of surgical intervention includes gastrotomy of the upper third of the gastric body and oversewing of the bleeding tears [217,218].
Management of patients receiving chronic antithrombotic therapy
If bleeding occurs in patients with Mallory-Weiss syndrome who are on chronic antithrombotic therapy (ATC code: B01A), discontinuation of these drugs is recommended; however, the balance between the risk of cardiovascular complications and the risk of recurrent bleeding must be weighed in each specific case [231-234].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Resumption of antithrombotic therapy is recommended as soon as stable hemostasis is achieved [231-234].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Patients who have experienced Mallory-Weiss bleeding are recommended sanatorium-resort treatment in sanatorium facilities within the patient's climate zone of residence [230,239].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: sanatorium-resort treatment lasting 14-21 days is recommended for patients with Mallory-Weiss syndrome. Sanatorium-resort treatment is carried out in sanatoriums in cities such as Dorokhovo, Yessentuki, Zheleznovodsk, etc., and includes mud baths and peat therapy, pine-sea baths, and drinking alkaline mineral water [230,239].
5. Prevention and Dispensary Observation
All individuals with H. pylori infection, in the absence of contraindications, are recommended to undergo eradication therapy [52].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
6. Organization of Medical Care
An indication for emergency hospitalization is the presence of signs of upper gastrointestinal bleeding.
Every clinic providing care for patients with acute upper gastrointestinal bleeding (including Mallory-Weiss bleeding) must have a local protocol for the multidisciplinary management of such patients. The diagnostic and treatment protocol must be based on national clinical guidelines and take into account the specific features of emergency care delivery and equipment of the particular medical institution.
In compliant patients with Mallory-Weiss syndrome and mild bleeding, low risk of bleeding recurrence, and no comorbid conditions, early hospital discharge is feasible.
7. Additional Information
7.1. Features of MWS course in specific patient groups
7.1.1 Features of MWS course during pregnancy
The course of Mallory-Weiss syndrome during pregnancy generally differs little from that in non-pregnant women. The diagnosis is established based on clinical manifestations, medical history, and EGD results [100]. X-ray examination of the stomach and duodenum is contraindicated in pregnant women.
Early toxicosis is characterized by distressing, almost constant nausea exacerbated by various smells, and salivation. Vomiting may occur regardless of food intake, especially in the mornings; abdominal pain is typically absent. Bleeding caused by Mallory-Weiss syndrome must be differentiated from bleeding due to peptic ulcer disease, erosive gastritis, gastric cancer, and respiratory tract bleeding.
Eradication therapy for H. pylori infection is not performed in pregnant women.
7.1.2 Features of MWS course in elderly and senile patients
In the development of Mallory-Weiss syndrome in elderly patients—in addition to H. pylori infection and the acid-peptic factor—atherosclerotic changes in gastric vessels, certain underlying conditions (e.g., chronic non-specific lung diseases) that reduce the protective properties of the gastric mucosa, and the use of medications (primarily NSAIDs) with ulcerogenic action may also play a role.
Pharmacotherapy should be administered with caution, given the higher risk of adverse effects in elderly patients compared to young and middle-aged patients.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Yes/no |
|---|---|---|
1. | Gastric sounding (A11.16.009) was performed with subsequent gastric lavage prior to EGD. | |
2. | Esophagogastroduodenoscopy performed | |
3. | Hemostasis (A16.12.020 Arrest of bleeding from a peripheral vessel) was performed via a flexible medical endoscope for ongoing bleeding from esophageal and/or gastric tears. | |
4. | Administration of balanced salt solutions (B05CB) was performed in the presence of hemodynamic instability. | |
5. | Blood transfusion was performed when the hemoglobin level was less than 70 g/L. | |
6. | Fresh frozen plasma transfusion was performed in the presence of hypocoagulation and ongoing bleeding or a high risk of its recurrence. | |
8. | Patients with ongoing or repeatedly recurrent bleeding with ineffectiveness (or impossibility) of endoscopic hemostasis underwent endovascular vessel embolization (gastric arteries) or surgical treatment. |
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Mertens, Alexander MD*; Essing, Tobias*,†; Roderburg, Christoph MD*; Luedde, Tom MD*; Kandler, Jennis MD*; Loosen, Sven H. MD*. A Systematic Analysis of Incidence, Therapeutic Strategies, and In-hospital Mortality of Mallory-Weiss Syndrome in Germany. Journal of Clinical Gastroenterology 58(7):p 640-649, August 2024. | DOI: 10.1097/MCG.0000000000001918
Monnet X, Teboul J-L. Transpulmonary thermodilution: advantages and limits. Critical Care. 2017;21(1):147. https://doi.org/10.1186/s13054-017-1739-5
Atkinson M. Mechanisms protecting against gastro-oesophageal reflux: a review. Gut. 1962 Mar;3(1):1-15. doi: 10.1136/gut.3.1.1. PMID: 13863110; PMCID: PMC1413309.
Aleksandrovich Yu.S. Evaluation and prognostic scales in critical care medicine / Aleksandrovich Yu.S., Gordeev V.I. // Sotis Publishing House; 2007. 140 p.
Allgöwer-Burri (1967) cit. by Klimansky V.A. and Rudaev A.Ya. – Transfusion therapy in surgical diseases // M., 1984. p. 255.
Shrestha MP, Borgstrom M, Trowers E. Digital Rectal Examination Reduces Hospital Admissions, Endoscopies, and Medical Therapy in Patients with Acute Gastrointestinal Bleeding. Am J Med. 2017 Jul;130(7):819-825. doi: 10.1016/j.amjmed.2017.01.036. Epub 2017 Feb 24. PMID: 28238693.
Alekseeva E.V., Popova T.S., Tropskaya N.S. Some aspects of using the prokinetic properties of erythromycin // Kremlin Medicine. Clinical Bulletin. 2009;4:80-86.
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Appendix A1. Working Group Composition
Gromov D.G., Doctor of Medical Sciences, Member of the Russian Scientific Society of Interventional Cardioangiologists. No conflict of interest.
Zatevakhin I.I., Doctor of Medical Sciences, Professor, Academician of the RAS, Member of the Russian Society of Surgeons. No conflict of interest.
Zakharchenko I.A., Candidate of Medical Sciences, Member of the Federation of Anesthesiologists and Intensivists. No conflict of interest.
Korolev M.P., Doctor of Medical Sciences, Professor, Member of the Russian Society of Surgeons. No conflict of interest.
Korymasov E.A., Doctor of Medical Sciences, Professor, Member of the Russian Society of Surgeons. No conflict of interest.
Olovyanniy V.E., Doctor of Medical Sciences, Member of the Russian Society of Surgeons. No conflict of interest.
Pavlychev A.V., Candidate of Medical Sciences, Member of the Russian Society of Surgeons. No conflict of interest.
Revishvili, A.Sh., MD, PhD, Professor, Academician of the Russian Academy of Sciences, Director of the A.V. Vishnevsky National Medical Research Center of Surgery of the Russian Ministry of Health, Chief Freelance Surgeon and Endoscopist of the Russian Ministry of Health. No conflict of interest.
Tarasenko, S.V., MD, PhD, Professor, Member of the Russian Society of Surgeons. No conflict of interest.
Fedorov, A.V., MD, PhD, Professor, Secretary-General of the Russian Society of Surgeons. No conflict of interest.
Fedorov, E.D., MD, PhD, Professor, President of the ENDO-RENDO Endoscopic Society Association. No conflict of interest.
Khripun, A.I., MD, PhD, Professor, Board Member of the Russian Society of Surgeons. No conflict of interest.
Shabunin, A.V., MD, PhD, Professor, Academician of the Russian Academy of Sciences, Member of the Russian Society of Surgeons. No conflict of interest.
Shchegolev, A.A., MD, PhD, Professor, Member of the Russian Society of Surgeons. No conflict of interest.
Anishchenko, M.A., PhD, Member of the ENDO-RENDO Endoscopic Society Association. No conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience of these clinical guidelines
Gastroenterologists.
General practitioners (family physicians).
Surgeons.
Endoscopists.
Anesthesiologists-resuscitators.
Endovascular surgeorns.
Clinical residents.
Methodology for evidence collection
Methods used for evidence collection/selection:
Search for publications in specialized peer-reviewed periodicals with an impact factor > 0.3;
Search in electronic databases
Databases used for evidence collection/selection:
The evidence base for the guidelines includes publications from the Cochrane Library, PubMed, and MEDLINE databases. The search depth was 30 years.
Methods used for analyzing evidence:
reviews of published meta-analyses;
systematic reviews with evidence tables.
Methods used for assessing the quality and strength of evidence:
expert consensus;
assessment of evidence significance in accordance with the evidence rating scheme.
Table S1 – Level of Evidence (LoE) rating scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference method controls or systematic reviews of randomized clinical trials using meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without sequential reference-standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table S2 – Level of Evidence (LoE) rating scale for methods of prevention, treatment, and medical rehabilitation, including those based on the use of natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of randomized controlled trials with meta-analysis |
2 | Individual randomized clinical trials and systematic reviews of studies of any design, excluding randomized clinical trials, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table S3. Grade of Recommendation (GoR) rating scale for methods of prevention, diagnostics, treatment, and medical rehabilitation, including those based on the use of natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
C | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines
Updating is carried out at least once every three years, or earlier taking into account new information on patient diagnostics and management that has become available, but no more frequently than once every 6 months. The generated proposals must take into account the results of a comprehensive assessment of medicines, medical devices, and clinical approbation results.
Appendix A3. Reference Materials
These clinical guidelines have been developed taking into account the following regulatory and legal documents:
Order of the Russian Ministry of Health No. 103n dated February 28, 2019, "On approval of the procedure and timelines for the development of clinical guidelines, their revision, the standard form of clinical guidelines and requirements for their structure, composition, and scientific validity of the information included in clinical guidelines".
Order of the Russian Ministry of Health No. 104n dated February 28, 2019, "On approval of the procedure and timelines for the approval and endorsement of clinical guidelines, criteria for the Scientific and Practical Council to make a decision on approving, rejecting, or sending clinical guidelines for revision, or a decision on their revision".
Order of the Russian Ministry of Health No. 922n dated November 15, 2012, "On approval of the Procedure for Providing Medical Care to the Adult Population in the Profile 'Surgery'".
Clinical Guidelines of the Ministry of Health of the Russian Federation "Peptic Ulcer Disease" (ID 277).
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
The main cause of Mallory-Weiss syndrome currently is an increase in intra-abdominal pressure (usually caused by vomiting), which leads to a rupture of the esophageal and/or gastric wall, followed by bleeding from the rupture margins. A predisposing factor is the presence of a hiatal hernia, as well as diseases of the upper gastrointestinal tract.
Such a patient must follow a diet (frequent, small meals; chemically, mechanically, and thermally sparing food), and be very cautious when taking medications that have a damaging effect on the mucosa of the stomach and duodenum (acetylsalicylic acid**, nonsteroidal anti-inflammatory and antirheumatic drugs). Alcohol consumption and smoking must be avoided.
Esophagogastric bleeding is a severe manifestation of Mallory-Weiss syndrome. Bleeding is typically characterized by hematemesis with clots after repeated dry heaving, the onset of weakness, dizziness, pallor of the skin, and other signs of acute blood loss. The condition is accompanied by vomiting of blood and/or tarry foul-smelling stools (melena). The patient must be laid down before the ambulance arrives, ensuring that aspiration of vomitus does not occur. Intake of food and liquids is prohibited.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Appendix G1.
Severity of blood loss.
Source: Gorbashko A.I. Diagnostics and treatment of blood loss / A.I. Gorbashko – L., 1982. – 224.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: determination of the severity of blood loss.
Content:
Key (interpretation): present in the table.
Notes: not required.
Blood loss indicator | Severity of blood loss | ||
|---|---|---|---|
Mild | Mean | Severe | |
Red blood cell count | > 3.5•1012/L | 3.5•1012/L - 2.5•1012/L | < 2.5•1012/L |
Hemoglobin level, g/L | > 100 | 83—100 | < 83 |
Pulse rate per 1 min. | Up to 80 | 80—100 | Above 100 |
Systolic BP (mmHg) | > 110 | 110—90 | < 90 |
Hematocrit value, % | > 30 | 25 – 30 | < 25 |
BCC deficit, % of normal | Up to 20 | From 20 to 30 | 30 or more |
Appendix G2.
ACS Bleeding Severity Score.
Original name: American College Of Surgeons Bleeding Score.
Source: American College of Surgeons Committee on Trauma / ATLS® Student Manual 10th Edition. Chicago: American College of Surgeons; 2018.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: determination of the severity of blood loss.
Content:
Parameter | Class 1 Mild blood loss | Class 2 Moderate blood loss | Class 3 Moderately severe blood loss | Class 4 Severe blood loss |
|---|---|---|---|---|
Estimated blood loss (% of BCC), mL | up to 15%, up to 750 | 15–30 %, 750-1000 | 30–40 %, 1500–2000 | > 40 %, More than 2000 |
HR (bpm) | N | N/ ↑ | ↑ | ↑/↑↑ |
Blood pressure | N | N | N /↓ | ↓↓ |
Pulse pressure | N | ↓ | ↓ | ↓ |
Capillary refill time (blanching test) | N | ↑ | ↑ | ↑↑ |
Respiratory rate | N | N | N/↑ | ↑ |
Diuresis (mL/h) | N | N | ↓ | ↓↓ |
N | N | ↓ | ↓ | |
BE (base deficit) mmol/l | 0-2 | -2 -6 | -6 -10 | Less than -10 |
Need for blood components | monitoring | possible | necessary | massive transfusion protocol |
Key (interpretation): present in the table.
Notes: not required.
Appendix G3.
AIMS65 score.
Original name: The AIMS65 Score.
Source: Hyett B.H., Abougergi M.S., Charpentier J.P., Kumar N.L., Brozovic S, Claggett BL, Travis AC, Saltzman JR. The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding. Gastrointest Endosc. 2013 Apr;77(4):551-7. doi: 10.1016/j.gie.2012.11.022.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: prediction of in-hospital mortality, need for blood transfusion, and ICU admission.
Content:
Sign | Significance | Score |
|---|---|---|
Albumin (g/dL) | < 3.0 | 1 |
INR | > 1.5 | 1 |
Mental status | Altered | 1 |
Age | > 65 | 1 |
Systolic blood pressure | < 90 | 1 |
Key (interpretation): in the absence of the above risks, in-hospital mortality is 0.3% compared to 31.8% in patients with 5 points.
An AIMS65 score >2 points in patients with peptic ulcer bleeding indicates the need for blood transfusion, ICU admission, and high risk of in-hospital mortality
Comments: not required.
Appendix G4.
Glasgow-Blatchford score.
Original name: The Glasgow-Blatchford Bleeding Score.
Source: Chandra S, Hess EP, Agarwal D, Nestler DM, Montori VM, Song LM, Wells GA, Stiell IG. External validation of the Glasgow-Blatchford Bleeding Score and the Rockall Score in the US setting. Am J Emerg Med. 2012 Jun;30(5):673-9. doi: 10.1016/j.ajem.2011.03.010.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: prediction of the need for blood transfusion, invasive intervention, ICU admission, and in-hospital mortality.
Content:
Risk features upon admission | Score |
|---|---|
Blood urea, mmol/L | |
6,5-7,9 | 2 |
8,0-9,9 | 3 |
10,0-24,9 | 4 |
≥ 25,0 | 6 |
Hemoglobin in men, g/L | |
120 – 129 | 1 |
100 – 119 | 3 |
< 100 | 6 |
Hemoglobin in women, g/L | |
100 – 119 | 1 |
< 100 | 6 |
Systolic blood pressure (mmHg) | |
100 – 109 | 1 |
90 – 99 | 2 |
< 90 | 3 |
Other features | |
Pulse ≥ 100 bpm | 1 |
Presence of melena | 1 |
Loss of consciousness | 2 |
History of liver disease | 2 |
Heart failure | 2 |
Key (interpretation): scores > 6 are associated with more than a twofold increased risk of requiring endoscopic, endovascular, or surgical intervention.
Comments: not required.
Appendix G5.
Rockall risk score.
Original name: The Rockall Risk Scoring System.
Source: Vreeburg EM, Terwee CB, Snel P, Rauws EA, Bartelsman JF, Meulen JH, Tytgat GN. Validation of the Rockall risk scoring system in upper gastrointestinal bleeding. Gut. 1999 Mar;44(3):331-5. doi: 10.1136/gut.44.3.331.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: prediction of in-hospital mortality and rebleeding.
Content:
Parameter | Score | |||
|---|---|---|---|---|
0 | 1 | 2 | 3 | |
Age (years) | Under 60 | 60–79 | 80 and older | |
Shock HR (bpm) Systolic BP | No shock < 100 ≥ 100 mmHg | Tachycardia ≥ 100 ≥ 100 | Hypotension – < 100 mmHg | – |
Comorbidities | Absent | – | CHD, heart failure, other "major" comorbidities | Renal failure, liver failure, disseminated malignancies |
Diagnosis | Mallory-Weiss syndrome or no lesions and no stigmata of recent hemorrhage | All other diagnoses | Malignancies of the upper GI tract | – |
Stigmata of recent upper GI bleeding | None or dark spots in the ulcer base | – | Blood in the upper GI tract, adherent clot, visible vessel, or spurting hemorrhage | – |
Key (interpretation): A scoring system for assessing the risk of rebleeding and mortality in patients with upper GI bleeding.
Total score calculation:
0–2: minimal risk of recurrence < 6%, mortality < 2%.
3–7: high risk of recurrence < 40%, mortality < 40%.
≥ 8: patients in critical condition, risk of recurrence ≥ 40%, mortality ≥ 40%.
Comments: not required
Appendix G6.
Original name: Allgower index.
Source: Allgower-Burri (1967) cited in Klimansky V.A., Rudaev A.Ya. – Transfusion therapy in surgical diseases // M., 1984. – p. 255.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose:
Determination of blood loss volume based on the ratio of heart rate (HR) to systolic blood pressure (SBP).
Content, key, and interpretation:
Normally, this ratio (Allgower index) HR/SBP = 60/120 = 0.5.
HR/SBP = 1 (100/100), blood loss volume is approximately 20% of circulating blood volume (CBV), which is within 1–1.2 liters for an adult. Shock I.
HR/SBP = 1.5 (120/80), blood loss is approximately 30–40% of CBV, or 1.5–2 liters for an adult. Shock II.
HR/SBP = 2 (120/60), blood loss is 50% of CBV or more than 2 liters. Shock III.