eMedicine Specialties > Gastroenterology > Esophagus

Mallory-Weiss Tear

Author: Louis-Michel Wong Kee Song, MD, Assistant Professor, Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic
Contributor Information and Disclosures

Updated: Apr 16, 2008

Introduction

Background

Mallory-Weiss syndrome is characterized by upper gastrointestinal bleeding secondary to longitudinal mucosal lacerations at the gastroesophageal junction or gastric cardia. The original description by Mallory and Weiss in 1929 involved patients with persistent retching and vomiting following an alcoholic binge. However, Mallory-Weiss syndrome may occur after any event that provokes a sudden rise in intragastric pressure or gastric prolapse into the esophagus.

Pathophysiology

A Mallory-Weiss tear (MWT) likely occurs as a result of a large, rapidly occurring, and transient transmural pressure gradient across the region of the gastroesophageal junction. Acute distension of the nondistensible lower esophagus can also produce a linear tear in this region.

With a rapid rise in intragastric pressure due to precipitating factors, such as retching or vomiting, the transmural pressure gradient increases dramatically across the hiatal hernia, which abuts a low intrathoracic pressure zone. If the shearing forces are high enough, a longitudinal laceration eventually occurs. Within the hernia, the tear is more likely to involve the lesser curvature of the gastric cardia, which is relatively immobile compared to the remainder of the stomach.

Another potential mechanism for MWTs is the violent prolapse or intussusception of the upper stomach into the esophagus, as can be witnessed during forceful retching at endoscopy.

Frequency

United States

MWTs account for 1-15% of cases of upper gastrointestinal bleeding.

International

Prevalence probably is similar to that in the United States.

Mortality/Morbidity

  • Bleeding from MWTs stops spontaneously in 80-90% of patients. With conservative therapy, most tears heal uneventfully within 48 hours. Thus, a MWT can easily be missed if endoscopy is delayed.
  • The degree of blood loss varies. Earlier studies reported that the proportion of patients requiring blood transfusions was 40-70%. These figures do not seem to be the trend today and are probably significantly lower.
  • Hemodynamic instability and shock may occur in up to 10% of patients. In one series, mortality as high as 8.6% was attributed to MWTs. Current clinical experience suggests a significantly lower mortality rate from MWTs.

Race

MWTs have no racial predilection.

Sex

Most studies report a male predominance. Male-to-female ratios reportedly are 2-4:1.

Age

Patients usually present in their 40s or 50s, but the age range is quite wide.

Clinical

History

  • The classic presentation consists of an episode of hematemesis following a bout of retching or vomiting, although this presentation may be less common than previously thought. Graham and Schwartz found that a typical history was obtained in only about 30% of patients.1 In a study by Harris and DiPalma, hematemesis on first emesis was reported in 50% of patients.2
  • Hematemesis is present in 85% of patients.
  • Less common presenting symptoms include melena, hematochezia, syncope, and abdominal pain.
  • Excessive alcohol use has been reported in 40-75% of patients, and aspirin use has been reported in up to 30% of patients.
  • Attempt to identify a precipitating factor for the MWT (see Causes).

Physical

  • MWTs do not elicit specific physical signs.
  • Physical findings relate to the rate and the degree of gastrointestinal blood loss. Tachycardia, hypotension, orthostatic changes, or overt shock may be evident.

Causes

  • The presence of a hiatal hernia is a predisposing factor and is found in 35-100% of patients with MWTs. During retching or vomiting, the transmural pressure gradient is greater within the hernia than the rest of the stomach, and it is the location most likely to sustain a tear. Precipitating factors include retching, vomiting, straining, hiccuping, coughing, primal scream therapy, blunt abdominal trauma, and cardiopulmonary resuscitation.
  • Iatrogenic tears are uncommon, considering the frequency with which patients retch during endoscopy. The reported prevalence is 0.07-0.49%.
  • In a few cases, no apparent precipitating factor can be identified. In one study, 25% of patients had no identifiable risk factor.

More on Mallory-Weiss Tear

Overview: Mallory-Weiss Tear
Differential Diagnoses & Workup: Mallory-Weiss Tear
Treatment & Medication: Mallory-Weiss Tear
Follow-up: Mallory-Weiss Tear
Multimedia: Mallory-Weiss Tear
References
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References

  1. Graham DY, Schwartz JT. The spectrum of the Mallory-Weiss tear. Medicine (Baltimore). Jul 1978;57(4):307-18. [Medline].

  2. Harris JM, DiPalma JA. Clinical significance of Mallory-Weiss tears. Am J Gastroenterol. Dec 1993;88(12):2056-8. [Medline].

  3. Laine L. Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage. A prospective controlled trial. N Engl J Med. Jun 25 1987;316(26):1613-7. [Medline].

  4. Baker RW, Spiro AH, Trnka YM. Mallory-Weiss tear complicating upper endoscopy: case reports and review of the literature. Gastroenterology. Jan 1982;82(1):140-2. [Medline].

  5. Bataller R, Llach J, Salmeron JM, Elizalde JI, Mas A, Pique JM, et al. Endoscopic sclerotherapy in upper gastrointestinal bleeding due to the Mallory-Weiss syndrome. Am J Gastroenterol. Dec 1994;89(12):2147-50. [Medline].

  6. Bharucha AE, Gostout CJ, Balm RK. Clinical and endoscopic risk factors in the Mallory-Weiss syndrome. Am J Gastroenterol. May 1997;92(5):805-8. [Medline].

  7. Chung IK, Kim EJ, Hwang KY, Kim IH, Kim HS, Park SH, et al. Evaluation of endoscopic hemostasis in upper gastrointestinal bleeding related to Mallory-Weiss syndrome. Endoscopy. Jun 2002;34(6):474-9. [Medline].

  8. Huang SP, Wang HP, Lee YC, Lin CC, Yang CS, Wu MS, et al. Endoscopic hemoclip placement and epinephrine injection for Mallory-Weiss syndrome with active bleeding. Gastrointest Endosc. Jun 2002;55(7):842-6. [Medline].

  9. Jensen DM, Kovacs TOG, Freeman M. A multicenter randomized prospective study of gold probe versus heater probe for hemostasis of very severe ulcer or Mallory-Weiss bleeding. Gastrointest Endosc. 1992;38:235.

  10. Kim JW, Kim HS, Byun JW. Predictive factors of recurrent bleeding in Mallory-Weiss syndrome. Korean J Gastroenterol. Dec 2005;46(6):447-54.

  11. Knauer CM. Mallory-Weiss syndrome. Characterization of 75 Mallory-weiss lacerations in 528 patients with upper gastrointestinal hemorrhage. Gastroenterology. Jul 1976;71(1):5-8. [Medline].

  12. Kortas DY, Haas LS, Simpson WG, Nickl NJ 3rd, Gates LK Jr. Mallory-Weiss tear: predisposing factors and predictors of a complicated course. Am J Gastroenterol. Oct 2001;96(10):2863-5. [Medline].

  13. Llach J, Elizalde JI, Guevara MC, Pellise M, Castellot A, Gines A, et al. Endoscopic injection therapy in bleeding Mallory-Weiss syndrome: a randomized controlled trial. Gastrointest Endosc. Dec 2001;54(6):679-81. [Medline].

  14. Mallory GK, Weiss SW. Hemorrhages from lacerations of the cardiac orifice of the stomach due to vomiting. Am J Med Sci. 1929;178:506-12.

  15. Montalvo RD, Lee M. Retrospective analysis of iatrogenic Mallory-Weiss tears occurring during upper gastrointestinal endoscopy. Hepatogastroenterology. Jan-Feb 1996;43(7):174-7. [Medline].

  16. Park CH, Min SW, Sohn YH, Lee WS, Joo YE, Kim HS, et al. A prospective, randomized trial of endoscopic band ligation vs. epinephrine injection for actively bleeding Mallory-Weiss syndrome. Gastrointest Endosc. Jul 2004;60(1):22-7. [Medline].

  17. Pezzulli FA, Purnell FM, Dillon EH. The Mallory-Weiss syndrome. Case report and update on embolization versus intraarterial vasopressin results. N Y State J Med. Jun 1986;86(6):312-4. [Medline].

  18. Savides TJ, Jensen DM. Therapeutic endoscopy for nonvariceal gastrointestinal bleeding. Gastroenterol Clin North Am. Jun 2000;29(2):465-87, vii. [Medline].

  19. Stevens PD, Lebwohl O. Hypertensive emergency and ventricular tachycardia after endoscopic epinephrine injection of a Mallory-Weiss tear. Gastrointest Endosc. Jan-Feb 1994;40(1):77-8. [Medline].

  20. Sugawa C, Benishek D, Walt AJ. Mallory-Weiss syndrome. A study of 224 patients. Am J Surg. Jan 1983;145(1):30-3. [Medline].

  21. Yamaguchi Y, Yamato T, Katsumi N, Morozumi K, Abe T, Ishida H, et al. Endoscopic hemoclipping for upper GI bleeding due to Mallory-Weiss syndrome. Gastrointest Endosc. Apr 2001;53(4):427-30. [Medline].

  22. Younes Z, Johnson DA. The spectrum of spontaneous and iatrogenic esophageal injury: perforations, Mallory-Weiss tears, and hematomas. J Clin Gastroenterol. Dec 1999;29(4):306-17. [Medline].

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Further Reading

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Keywords

MWT, gastroesophageal tears, Mallory-Weiss syndrome, Mallory-Weiss lesion, upper gastrointestinal hemorrhage, retching, vomiting, mucosal lacerations, intragastric pressure, gastric prolapse, straining, hiccuping, coughing, primal scream therapy, blunt abdominal trauma, cardiopulmonary resuscitation, iatrogenic tears, portal hypertension, gastroesophageal varices, hiatal hernia

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Contributor Information and Disclosures

Author

Louis-Michel Wong Kee Song, MD, Assistant Professor, Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic
Louis-Michel Wong Kee Song, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Medical Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Medical Editor

Terence David Lewis, MBBS, FRACP, FRCPC, FACP, Program Director, Internal Medicine Residency, & Assistant Chairman, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, Loma Linda University Medical Center
Terence David Lewis, MBBS, FRACP, FRCPC, FACP is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, California Medical Association, Royal College of Physicians and Surgeons of Canada, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Douglas M Heuman, MD, FACP, Director of Hepatology, McGuire Veterans Affairs Medical Center, Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine
Douglas M Heuman, MD, FACP is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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