How should I approach the initial management of a patient presenting with hematemesis and a suspected Mallory-Weiss tear?

For a patient presenting with hematemesis and a suspected Mallory-Weiss tear, which is a form of non-variceal upper gastrointestinal bleeding, the initial management should focus on resuscitation, risk assessment, medication review, and timely endoscopy ¹.

• Resuscitation and Initial Management:
• Transfuse patients with massive bleeding with blood, platelets, and clotting factors in line with local protocols for managing massive bleeding ¹. Decisions on blood transfusion should be based on the full clinical picture, recognising that over-transfusion may be as damaging as under-transfusion ¹.
• Do not offer platelet transfusion to patients who are not actively bleeding and are haemodynamically stable ¹.
• Offer platelet transfusion to patients who are actively bleeding and have a platelet count of less than 50 x 10⁹/litre ¹.
• Offer fresh frozen plasma to patients who are actively bleeding and have a prothrombin time (or international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal ¹. If a patient's fibrinogen level remains less than 1.5 g/litre despite fresh frozen plasma use, offer cryoprecipitate as well ¹.
• Offer prothrombin complex concentrate to patients who are taking warfarin and actively bleeding ¹.
• Risk Assessment:
• Use the Blatchford score at first assessment for all patients with acute upper gastrointestinal bleeding ¹.
• Consider early discharge for patients with a pre-endoscopy Blatchford score of 0 ¹.
• Medication Review:
• Stop other non-steroidal anti-inflammatory drugs (NSAIDs), including cyclooxygenase-2 (COX-2) inhibitors, during the acute phase ¹.
• Discuss the risks and benefits of continuing clopidogrel (or any other thienopyridine antiplatelet agents) with the appropriate specialist (e.g., a cardiologist or a stroke specialist) and with the patient ¹.
• Continue low-dose aspirin for secondary prevention of vascular events in patients in whom haemostasis has been achieved ¹.
• Acid Suppression:
• Do not offer acid-suppression drugs (proton pump inhibitors or H₂-receptor antagonists) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding ¹.
• Offer proton pump inhibitors to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy ¹.
• Timing of Endoscopy:
• Offer endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation ¹.
• Offer endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding ¹.
• Information and Support:
• Establish good communication between clinical staff and patients and their family and carers at the time of presentation, throughout their time in hospital and following discharge ¹. This should include giving verbal information that is recorded in medical records, providing consistent information from different clinical teams, offering written information where appropriate, and ensuring consistent information for patients and their families/carers ¹.