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Mallory-Weiss syndrome

Author Section Editor Deputy Editor

Moises Guelrud, MD Mark Feldman, MD, MACP, AGAF, Anne C Travis, MD, MSc, FACG,
FACG AGAF

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2014. | This topic last updated: Mar 14, 2014.

INTRODUCTION — Mallory-Weiss syndrome is characterized by longitudinal mucosal lacerations (intramural

dissections) in the distal esophagus and proximal stomach, which are usually associated with forceful retching. The
lacerations often lead to bleeding from submucosal arteries. Since the initial description in 1929 by Mallory and
Weiss in 15 alcoholic subjects [1], gastroesophageal tears have been a recognized cause of upper gastrointestinal
hemorrhage. The prevalence of such tears among patients presenting with upper gastrointestinal bleeding is
approximately 5 percent [2-4]. Rarely, perforation can occur with repeated, protracted vomiting. (See "Major causes
of upper gastrointestinal bleeding in adults" and "Boerhaave's syndrome: Effort rupture of the esophagus".)

How frequently a Mallory-Weiss tear occurs without bleeding cannot be determined with any certainty. It is highly
likely that the condition occurs in a less severe form more frequently than is recognized. As an example, the
incidence of Mallory-Weiss tears in patients receiving colonoscopic preparation with polyethylene glycol electrolyte
lavage solution has been reported at 0.06 percent (2 of 3172 patients) [5]. In comparison, we found a higher rate
when we studied 1248 consecutive patients receiving a standard preparation of polyethylene glycol electrolyte
lavage solution with gastroscopy followed immediately by colonoscopy [6]. A Mallory-Weiss tear was found in 13
patients (1 percent); four developed active bleeding and nine were asymptomatic tears incidentally diagnosed during
endoscopy.

PATHOGENESIS — The pathogenesis of this syndrome is not completely understood. Mallory-Weiss tears are
usually secondary to a sudden increase in intraabdominal pressure. Precipitating factors include vomiting, straining
at stool or lifting, coughing, epileptic convulsions, hiccups under anesthesia, closed-chest massage, blunt abdominal
injury, colonoscopic preparation with polyethylene glycol electrolyte lavage solution, and gastroscopy [2-5,7-9]. A
case report described fatal bleeding following transesophageal echocardiography and placement of a nasogastric
tube during cardiac surgery [10]. The frequency of Mallory-Weiss tears following endoscopic examination appears to
be low. In a national survey of the American Society for Gastrointestinal Endoscopy, a tear was found in 0.13 percent
of 2320 patients undergoing gastroscopy [11]. Predisposing conditions to Mallory-Weiss tears include hiatal hernia,
chronic alcoholism, and perhaps increasing age [3,4,8,12-15].

Hiatal hernia — Hiatal hernia has been found in 40 to 100 percent of patients with Mallory-Weiss tears and has
been considered by some to be a necessary predisposing factor [12]. It has been proposed that, in hiatus hernia, a
higher pressure gradient develops in the hernia compared with that in the rest of the stomach during retching,
thereby increasing the potential for mucosal laceration. Gastroesophageal tears may also be more likely to occur
when the upper esophageal sphincter does not relax during vomiting. (See "Hiatus hernia".)

Alcoholism — A history of heavy alcohol use leading to vomiting has been noted in 40 to 80 percent of patients with
Mallory-Weiss syndrome in most series [4,12-15]. The bleeding is usually more severe when Mallory-Weiss tears are
associated with portal hypertension and esophageal varices [16,17]. Occasionally, patients give a history of ingestion
of aspirin or nonsteroidal anti-inflammatory drug.

Age — Increasing age has been advocated as a predisposing factor of Mallory-Weiss tears [8]. In a small series, six
of seven patients with tears occurring during endoscopy were elderly, suggesting a possible increase in vulnerability
of the atrophic gastric mucosa in these subjects. However, most tears occur in patients under the age of 40,
suggesting that age does not play a major role. Tears have also occurred in children as young as three weeks of age
[18].
CLINICAL MANIFESTATIONS — Acute gastrointestinal bleeding is the major clinical manifestation, which may be
accompanied by epigastric pain or pain in the back. Bleeding occurs when the tear involves the underlying
esophageal venous or arterial plexus. Patients usually, but not always, give a history of nonbloody vomiting or
retching before the onset of hematemesis [13].

The amount of blood loss is usually small and self-limited. However, massive hemorrhage requiring transfusions and
even leading to death can occur [19]. Active bleeding at the time of initial endoscopy and a low initial hematocrit
have a high association with a complicated course [20]. These data add further support to early endoscopy in
patients with clinically significant upper gastrointestinal hemorrhage.

DIAGNOSIS — Endoscopy is the diagnostic modality of choice to document the presence of a gastroesophageal
tear, and it allows the possibility of therapeutic intervention. The tears are located in the esophagogastric junction,
often within a hiatal hernia; they usually extend downward into the cardia and sometimes upward into the esophagus
[14].

Mallory-Weiss tears are usually single and longitudinal. However, multiple mucosal tears have been found in up to
27 percent of cases [14,15]. On endoscopy, the tears typically appear as a red longitudinal crack in the mucosa
(picture 1), sometimes extending through the muscularis mucosa (picture 2), and occasionally covered by a clot
(picture 3). Active bleeding may also be noted (picture 4). In many instances, the lesions are recognized only after
retroflexion of the tip of the gastroscope to view the cardia from below. Most tears heal uneventfully within 24 to 48
hours in patients without portal hypertension; as a result, they may not be seen if endoscopy is delayed.

Mallory-Weiss tears must be distinguished from other ulcerative diseases of the esophagus, including ulcerative
reflux esophagitis, infectious esophagitis, or pill-induced esophageal ulcers. Mallory-Weiss tears are usually focal
lesions with normal appearing adjacent mucosa. In contrast, there is typically diffuse involvement of the distal
esophagus with reflux or infectious esophagitis, while pill-induced ulcers are suspected by the history (eg, use of a
drug such as tetracycline or alendronate) and are located more proximally in the esophagus. (See "Medication-
induced esophagitis".)

TREATMENT — Although 40 to 70 percent of patients with bleeding Mallory-Weiss tears require blood transfusions,
most tears heal spontaneously [14,21]. A classification scheme has been proposed to identify patients at risk for
recurrent bleeding and mortality and those patients requiring only brief hospitalization [22]. Portal hypertension and
coagulopathy were identified as the major risk factors for rebleeding. Rebleeding usually occurred within 24 hours
and most often in patients with a coagulopathy. Clinical features that indicated a severe bleed were those of
hematochezia and hemodynamic instability.

Endoscopic therapy is the first-line treatment for actively bleeding lacerations. Several hemostatic methods have
been used to control bleeding. The results obtained with any modality depend upon technique, experience, and
practice.

Injection therapy of various agents, including epinephrine [5,21,23], ethanol [5,24], and other sclerosants [23] has
been used as monotherapy or in combination with thermal devices.

● Injection of epinephrine (1:10,000 to 20,000) diminishes arterial blood flow by a combination of vasoconstriction
and edema permitting more effective thermal therapy. Epinephrine has also been used successfully in
combination with polidocanol (a sclerosing agent) [25].

● Bipolar or multipolar electrocoagulation (eg, a bipolar probe at 15 watts, mild tamponade, and one second
pulses) is the most popular thermal therapy. It is effective, safe, inexpensive, and most endoscopists have
experience with this technique. However, there are few prospective studies or randomized trials looking at
effectiveness. The technique for Mallory-Weiss syndrome is generally similar to that used for bleeding ulcers,
but less tamponade force and lower total energy is usually recommended because of the smaller size of the
underlying artery and a desire to avoid perforation. In one small study of patients with active arterial bleeding
from a Mallory-Weiss tear, treatment with multipolar electrocoagulation significantly decreased the rate of
continued bleeding, the number of transfusions required, and rate of emergency surgery when compared with
medical therapy [26].

Thermal coagulation should not be performed in patients with portal hypertension and esophageal varices since it
may precipitate or worsen bleeding; sclerotherapy or endoscopic variceal ligation is preferable in such cases.
Another limiting factor is that the esophagus lacks a serosa and may be very thin at the tear site. Thus, repeated
coagulation should be avoided because of the risk of transmural injury and perforation [23].

Another approach that has been described in case reports and small controlled trials is the use of endoscopic band
ligation. Similar to variceal band ligation, the affected mucosa is suctioned into the ligating device after which the
band is applied [27-30].

Successful hemostasis using hemoclips has also been reported [9,31,32]. Hemoclips were as effective as
epinephrine injection in patients with spurting vessels or oozing lesions in a small randomized trial [33]. A
prospective study comparing band ligation with hemoclip placement in 41 patients found that both methods were
equally effective and safe for management of actively bleeding Mallory-Weiss tears [34].

A retrospective study comparing band ligation with hemoclips plus epinephrine injection in 56 patients found that
endoscopic hemostasis was achieved in all patients [35]. However, recurrent bleeding occurred in 0 percent in the
banding group versus 18 percent in the hemoclip plus epinephrine group (p = 0.02). (See "Endoclip therapy in the
gastrointestinal tract: Bleeding lesions and beyond".)

Intravenous infusion of vasopressin, esophageal balloon tamponade, and angiographic arterial embolization have
been used occasionally to control severe or refractory hemorrhage [2,4,36]. Surgery, with oversewing of the bleeding
vessel, may be necessary in those rare instances when bleeding cannot be controlled.

We place all patients on a proton pump inhibitor, although the benefit for preventing rebleeding in Mallory-Weiss
syndrome has not been well-studied.

PROGNOSIS — Almost all patients with Mallory-Weiss syndrome will respond to endoscopic hemostatic therapy,
and mortality is similar to that seen with bleeding from peptic ulcer disease. A retrospective study comparing the 30-
day mortality in 281 patients with endoscopically confirmed Mallory-Weiss syndrome and 1530 patients with peptic
ulcer bleeding found that the mortality rate was 5.3 percent for patients with bleeding Mallory-Weiss syndrome and
4.6 percent for patients with peptic ulcer bleeding (p = 0.58). In both patients with bleeding Mallory-Weiss syndrome
and peptic ulcer bleeding, mortality was significantly higher in patients over 65 years of age and those with
significant overall comorbidities [37].

SUMMARY AND RECOMMENDATIONS

● Mallory-Weiss syndrome is characterized by longitudinal mucosal lacerations (intramural dissections) in the

distal esophagus and proximal stomach that are usually associated with forceful retching. (See 'Introduction'
above.)

● Acute gastrointestinal bleeding is the major clinical manifestation of Mallory-Weiss syndrome and may be
accompanied by epigastric pain or pain in the back. Bleeding occurs when the tear involves the underlying
esophageal venous or arterial plexus. Patients usually, but not always, give a history of nonbloody vomiting or
retching before the onset of hematemesis. (See 'Clinical manifestations' above.)

● Endoscopy is the diagnostic modality of choice to document the presence of a gastroesophageal tear, and it
allows the possibility of therapeutic intervention. (See 'Diagnosis' above.)

● We suggest that patients without risk factors for rebleeding (ie, portal hypertension and/or coagulopathy),
clinical features indicating severe bleeding (ie, hematochezia and hemodynamic instability), or active bleeding
at endoscopy be managed medically with a brief hospitalization of 24 hours (Grade 2C). Almost all such
patients will heal spontaneously. (See 'Treatment' above.)

● We suggest that patients not actively bleeding at endoscopy but with clinical risk factors for rebleeding and/or
nonbleeding endoscopic stigmata such as a protruding visible vessel, pigmented protuberance, or fresh
adherent clot be observed for 48 hours (Grade 2C). (See 'Treatment' above.)

● Patients with active bleeding at endoscopy should be treated with endoscopic hemostasis. They should be
hospitalized for at least 48 hours because rebleeding generally occurs within 24 hours of the initial therapeutic
endoscopy. (See 'Treatment' above.)
● We suggest that all patients with Mallory-Weiss syndrome be treated with a proton pump inhibitor (Grade 2C).
(See 'Treatment' above.)

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REFERENCES

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Topic 2272 Version 3.0

GRAPHICS

Mallory-Weiss tear

Endoscopic diagnosis and treatment of Mallory-Weiss tears. Left panel:

A large esophageal laceration extending to the lower esophageal body.
Right panel: A large esophageal laceration below the gastroesophageal
junction seen by retroflexion of the tip of the gastroscope which also
visualized a hiatal hernia; previous bleeding was controlled by
multipolar electrocoagulation.

Courtesy of Moises Guelrud, MD.

Graphic 57049 Version 1.0

Mallory-Weiss tear

Endoscopy shows a mucosal tear extending into the muscularis mucosa

at the distal esophagus.

Courtesy of Moises Guelrud, MD.

Graphic 76980 Version 1.0

Mallory-Weiss tear

Endoscopy shows a Mallory-Weiss tear with an adherent clot at the

apex of the tear.

Courtesy of Moises Guelrud, MD.

Graphic 68239 Version 2.0

Mallory-Weiss tear

Endoscopy shows an actively bleeding Mallory-Weiss tear at the

gastroesophageal junction.

Courtesy of Moises Guelrud, MD.

Graphic 71690 Version 1.0

Disclosures
Disclosures: Moises Guelrud, MD Grant/Research/Clinical Trial Support: EMRk LLC [GI Endoscopy (EMRK compound)]. Mark
Feldman, MD, MACP, AGAF, FACG Nothing to disclose. Anne C Travis, MD, MSc, FACG, AGAF Employee of UpToDate, Inc. Equity
Ownership/Stock Options: Proctor & Gamble.
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