Mallory Weiss Syndrome


Article Author:
Prashanth Rawla


Article Editor:
Joe Devasahayam


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
6/26/2019 1:09:13 PM

Introduction

Mallory-Weiss syndrome (MWS) is one of the common causes of acute upper gastrointestinal (GI) bleeding, characterized by the presence of longitudinal superficial mucosal lacerations (Mallory-Weiss tears). These tears occur primarily at the gastroesophageal junction; they may extend proximally to involve the lower or even mid esophagus and at times extend distally to involve the proximal portion of the stomach.

Though Albers first reported lower esophageal ulceration in 1833, Kenneth Mallory and Soma Weiss in 1929, more accurately described this condition as lower esophageal lacerations (not ulcerations) happening to patients with repetitive forceful retching and vomiting following excessive alcohol intake.[1] 

Etiology

Heavy alcohol ingestion is considered to be one of the most important predisposing factors as about 50% to 70% of the patients diagnosed with Mallory-Weiss syndrome have a history of the same.[2] The severity of the upper GI bleeding with Mallory-Weiss syndrome is also reported to be higher with the concurrent presence of portal hypertension as well as esophageal varices.

The relationship between a hiatal hernia (protrusion of an organ, usually the upper part of the stomach into the chest cavity through the esophageal opening of the diaphragm) and Mallory-Weiss syndrome is still a matter of debate. A hiatal hernia was found in a considerable number of cases with Mallory-Weiss syndrome, while a case-control study conducted at the Mayo Clinic in Florida found no difference in the incidence of a hiatal hernia between patients with Mallory-Weiss syndrome and the control group.[3]

Other risk factors include bulimia nervosa, hyperemesis gravidarum, and gastroesophageal reflux disease (GERD). All these conditions involve regurgitation of gastric contents into the esophagus. However, in a considerable number of patients (around 25% of cases), none of those mentioned above risk factors were identified.

The condition is precipitated by repeated acts of a sudden increase of the intraabdominal pressure such as retching, vomiting, straining, coughing, cardiopulmonary resuscitation (CPR), or blunt abdominal traumas.

Iatrogenic Mallory-Weiss syndrome is generally uncommon. However, it can occur as a complication of invasive procedures like upper gastrointestinal endoscopy or trans-esophageal echocardiography (TEE).[4]  Upper gastrointestinal endoscopy procedure as such has only 0.07% to 0.49% complication rates to develop Mallory-Weiss syndrome, and hence the risk is low.

Epidemiology

MWS accounts for 1% to 15% of the causes of upper GI bleeding in adults and less than 5% in children in the United States. The age of highest incidence is between 40 and 60 years.[5] Males are 2 to 4 times more likely to develop Mallory-Weiss syndrome than women for unclear reasons. Hyperemesis being a frequent etiology for Mallory-Weiss syndrome in young women, pregnancy testing should be considered in such patients.

Pathophysiology

The exact mechanism by which Mallory-Weiss tears occur is still unknown. The suggested theory is that when the intraabdominal pressure suddenly and severely increases (as in cases of forceful retching and vomiting), the gastric contents rush proximally under pressure into the esophagus. This excess pressure from the gastric contents results in longitudinal mucosal tears which may reach deep into the submucosal arteries and veins, resulting in upper GI bleeding. These tears tend to be longitudinal, and not circumferential, possibly because of the cylindrical shape of the esophagus and stomach.[6]

History and Physical

The condition may be asymptomatic in mild cases. In 85% of cases, the presenting symptom is hematemesis. The amount of blood is variable; ranging from blood-streaked mucus to massive bright red bleeding.

In case of severe bleeding, other symptoms such as melena, dizziness, or syncope can be manifested. Epigastric pain is usually present and denotes the presence of a predisposing factor such as gastroesophageal reflux disease (GERD).

There are no physical signs specific to Mallory-Weiss syndrome, and the signs are similar to any other hemorrhagic conditions or shock. During a physical examination, clinicians must check signs of severe bleeding and shock, including but not limited to, tachycardia, thready pulse, hypotension, dehydration, reduced skin turgor, and capillary filling time and intervene immediately if they are present. The rectal examination could show signs of melena.

Evaluation

At presentation, all patients with hematemesis should receive immediate attention and care as appropriate. After obtaining a history and performing the physical examination, they should be triaged by the severity of bleeding. Some patients might have significant internal bleeding, and hence, proper history and examination for signs of shock are vital. Lab tests include complete blood count (CBC), hemoglobin and hematocrit, coagulation profile (bleeding time, prothrombin time, partial thromboplastin time, and platelet count). Chronic alcoholism results in low platelet count.

The lab tests should also include kidney functions to recognize the presence of renal failure by measuring blood urea nitrogen (BUN) and creatinine. The presence of renal failure would be most likely from pre-renal azotemia unless the patient had previous coexisting chronic kidney disease. Ruling out myocardial ischemia or infarction by measuring cardiac enzymes and performing a bedside electrocardiogram (ECG) is also essential.

Upper GI endoscopy is the gold standard for definitively diagnosing Mallory Weiss tears, and managing simple active esophageal bleeding. It may demonstrate active bleeding, a clot, or a fibrin crust over the tear. In most cases, a single linear tear found in the proximal part of the lesser curvature of the stomach just below the cardia, confirms the diagnosis. Upper GI endoscopy is also useful in discovering other causes of bleeding including esophageal varices, gastric or duodenal ulcers among others. Most Mallory Weiss tears measure about an inch in length.

Barium studies should be avoided due to their low diagnostic value and their interference with the endoscopic diagnosis.

Angiography is indicated in actively bleeding tears in case of failure or inaccessibility of endoscopy to locate the site of the bleeding tear and to stop the bleeding.

Treatment / Management

Since Mallory-Weiss syndrome is mostly self-limited and recurrence is uncommon, the initial management aims at stabilizing the general condition of the patient, and a conservative approach would be appropriate in most of the patients. 

Immediate resuscitation of patients with active bleeding should be started at the time of admission. We assess hemodynamic stability by checking airway, breathing, and circulation (ABC protocol). Establishment of a good central or peripheral intravenous (IV) access (usually 2 lines) along with fluid replacement could be life-saving in patients with severe bleeding. Packed RBCs infusion is indicated if the hemoglobin level is less than 8 gm/dl or if the patient presents with signs of shock or severe bleeding.

Nasogastric decompression using nasogastric tube could be performed, especially in patients suspected to have concomitant esophageal varices, before gastric lavage. Electrolyte imbalance, if present, should be corrected appropriately. Coagulation factors need to be optimized before proceeding with endoscopy.  Most patients managed conservatively are typically hospitalized until hemostasis is achieved and symptoms are resolved.

Pharmacological Treatment

Proton pump inhibitors (PPIs) and H2 blockers are given to decrease gastric acidity as increased acidity hinders the recovery of gastric and esophageal mucosa. Intravenous PPIs are given initially to patients who are expected to undergo endoscopic examination. Anti-emetics such as promethazine and ondansetron are given to control nausea and vomiting.

Endoscopic Treatment

Esophagogastroscopy is the investigation of choice in all cases of upper GI bleeding.[7] If bleeding had already stopped at the time of endoscopy,  no further intervention is generally needed. In situations with ongoing active or recurrent bleeding, there are different modalities of endoscopic treatment. Epinephrine local injection (1:10,000 to 1:20,000 dilution) stops the bleeding through vasoconstriction.[8][9] Multipolar electrocoagulation (MPEC), injection of a sclerosant agent, Argon plasma coagulation (APC), or endoscopic band ligation are other options in such situations.

Angiotherapy

Angiography with either injection of a vasoconstricting agent such as vasopressin or transcatheter embolization with gel foam to obliterate the left gastric or superior mesenteric artery is considered when endoscopy is not available or has failed.[10]

Surgical Treatment

Surgery is rarely necessary and is deemed necessary after the failure of endoscopic procedures or angiotherapy to stop the bleeding. Laparoscopic over-sewing of the tear under endoscopic guidance has been performed with excellent results.[11]

Sengstaken-Blakemore tube compression is the last resort in the treatment of a bleeding Mallory-Weiss tear in debilitated patients.[5] It is the least preferable option since the bleeding is mostly arterial and the pressure in the balloon is not enough to overcome the pressure in the bleeding artery.

Differential Diagnosis

Mallory Weiss syndrome should be differentiated from other causes of upper GI bleeding;

  • Boerhaave syndrome: A severe condition that shares the same predisposing factors with Mallory-Weiss syndrome, but the pathology is perforation of the esophagus
  • Peptic ulcer: A peptic ulcer is the most frequent cause of upper GI bleeding. It has its characteristic clinical picture and is diagnosed definitively by endoscopy.
  • Esophageal or gastric neoplasm
  • Esophageal varices: Dilated tortuous vessels around the lower esophagus, mostly as a complication of portal hypertension. Esophageal varices may also coexist with Mallory Weiss syndrome.
  • Arteriovenous malformations

Complications

Complications are related to the degree of blood loss, such as hypovolemic shock, metabolic disturbance, and myocardial infarction.[12] Death occurs if the bleeding is not controlled. Esophageal perforation and recurrence in Mallory Weiss syndrome are rare complications.

Deterrence and Patient Education

Although the condition is not very common, patients should be aware of the hazards of excessive alcohol drinking that include Mallory Weiss tears. It is important to counsel patients with previous episodes of hematemesis to avoid the precipitating factors that lead to esophageal tearing despite the rarity of recurrence.

Enhancing Healthcare Team Outcomes

Collaboration and effective communication with the other supporting healthcare teams are crucial to ensure excellent patient service. Gastroenterology, interventional radiology and surgery consultations should be appropriately obtained when necessary to provide the best treatment options and to ensure hemodynamical stability. The best approach that will lead to the most favorable outcome includes a coordinated multidisciplinary team made up of nurses, primary care, and specialists. 

The condition is generally very self-limited, and around 90% of the cases require only conservative management.[5] Healing of the tears occurs spontaneously with conservative treatment within 48 to 72 hours. Recurrence is very unlikely. Mortality from Mallory Weiss syndrome has significantly decreased due to the recent advances in the management of acute hemorrhage and shock.


  • Image 8563 Not availableImage 8563 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Mallory Weiss Syndrome - Questions

Take a quiz of the questions on this article.

Take Quiz
Which condition is most often associated with hematemesis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A male with alcohol use disorder presents to the emergency room with an episode of vomiting bright red blood. He says he has been drinking alcohol all day. He had a bout of severe retching and then suddenly noticed bright red blood in his vomitus. His vital signs are stable and his pulse is 110 beats/min. He is unable to give any significant past medical history. He is stabilized and an upper gastrointestinal tract endoscopy is performed. The etiology of his bleeding is felt to be a Mallory Weiss tear. Where are these tears most commonly located?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old patient vomited blood after continuously retching for hours. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A child has been repeatedly vomiting and retching for more than a day. His mother noticed a bloody vomit that worried her. What is the most likely cause of bleeding?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old girl comes to the emergency department with one episode of vomiting of blood. She has a history of severe nausea and vomiting over the past two weeks. She denies drinking alcohol in the last two months. She usually weighs 60 kgs, but she reports losing 4 kg of her weight over the previous month. On examination, she looks cachectic, mildly dehydrated. Blood pressure is 100/70 mmHg, and temperature 98.2 F; the respiratory rate is 16/minute. What is the first investigation to consider?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 32-year-old male presents to the emergency department after vomiting of a small amount of bright red blood. He has been suffering from severe gastroenteritis over the last three days with violent retching and vomiting. An upper gastrointestinal endoscopy was conducted and reveals linear mucosal lacerations of the lower esophagus. Which of the following abnormalities could be found as an association with this patient’s presenting condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 52-year-old man presents concerned that he had an attack of vomiting of blood three days ago when he was on vacation in Mexico. He reports having vomited each night during his 2-week trip to Mexico after heavy drinking. The last time he vomited was 3 days ago. His wife noticed that there was streaking of blood in his vomitus. His vital signs are as follows T 98.3 F, HR 76 bpm, BP 130/78 mmHg, RR 16/min, and O2 Sat 99%. What is the most likely finding if this patient undergoes an upper gastrointestinal endoscopic examination?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Mallory Weiss Syndrome - References

References

Cherednikov EF,Kunin AA,Cherednikov EE,Moiseeva NS, The role of etiopathogenetic aspects in prediction and prevention of discontinuous-hemorrhagic (Mallory-Weiss) syndrome. The EPMA journal. 2016     [PubMed]
Carr JC, The Mallory-Weiss Syndrome. Clinical radiology. 1973 Jan;     [PubMed]
Kortas DY,Haas LS,Simpson WG,Nickl NJ 3rd,Gates LK Jr, Mallory-Weiss tear: predisposing factors and predictors of a complicated course. The American journal of gastroenterology. 2001 Oct;     [PubMed]
Corral JE,Keihanian T,Kröner PT,Dauer R,Lukens FJ,Sussman DA, Mallory Weiss syndrome is not associated with hiatal hernia: a matched case-control study. Scandinavian journal of gastroenterology. 2017 Apr;     [PubMed]
Montalvo RD,Lee M, Retrospective analysis of iatrogenic Mallory-Weiss tears occurring during upper gastrointestinal endoscopy. Hepato-gastroenterology. 1996 Jan-Feb;     [PubMed]
Sugawa C,Benishek D,Walt AJ, Mallory-Weiss syndrome. A study of 224 patients. American journal of surgery. 1983 Jan;     [PubMed]
Hastings PR,Peters KW,Cohn I Jr, Mallory-Weiss syndrome. Review of 69 cases. American journal of surgery. 1981 Nov;     [PubMed]
Llach J,Elizalde JI,Guevara MC,Pellisé M,Castellot A,Ginès A,Soria MT,Bordas JM,Piqué JM, Endoscopic injection therapy in bleeding Mallory-Weiss syndrome: a randomized controlled trial. Gastrointestinal endoscopy. 2001 Dec;     [PubMed]
Gawrieh S,Shaker R, Treatment of actively bleeding Mallory-Weiss syndrome: epinephrine injection or band ligation? Current gastroenterology reports. 2005 Jun;     [PubMed]
Pezzulli FA,Purnell FM,Dillon EH, The Mallory-Weiss syndrome. Case report and update on embolization versus intraarterial vasopressin results. New York state journal of medicine. 1986 Jun;     [PubMed]
Kitano S,Ueno K,Hashizume M,Ohta M,Tomikawa M,Sugimachi K, Laparoscopic oversewing of a bleeding Mallory-Weiss tear under endoscopic guidance. Surgical endoscopy. 1993 Sep-Oct;     [PubMed]
Stevens PD,Lebwohl O, Hypertensive emergency and ventricular tachycardia after endoscopic epinephrine injection of a Mallory-Weiss tear. Gastrointestinal endoscopy. 1994 Jan-Feb;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Nurse-Corrections (CCN). The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Nurse-Corrections (CCN), it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Nurse-Corrections (CCN), you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Nurse-Corrections (CCN). When it is time for the Nurse-Corrections (CCN) board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Nurse-Corrections (CCN).