eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Mallory-Weiss Syndrome

Author: Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Contributor Information and Disclosures

Updated: Mar 8, 2010

Introduction

Background

In 1929, Kenneth Mallory and Soma Weiss first described a syndrome characterized by esophageal bleeding caused by a mucosal tear in the esophagus as a result of forceful vomiting or retching. The initial description was associated with alcoholic bingeing; however, with the advent of endoscopy, Mallory-Weiss tears have been diagnosed in many patients with no antecedent history of alcohol intake. Although the tear typically occurs after repeated episodes of vomiting or retching, it may occur after a single incident.¹ Although most written reports of these tears relate to adults, Mallory-Weiss tears also occur in children.

In pediatrics, Mallory-Weiss tears are recognized in children with predisposing medical conditions, including portal hypertension, liver cirrhosis, and severe gastroesophageal reflux disease. The clinical implications in these pediatric patients are noteworthy, especially because these children are predisposed to recurrent upper GI bleeding.² The associated risk of morbidity and mortality must also be underscored.

Examples of Mallory-Weiss tears are shown in the images below.

Pathophysiology

Any disorder that initiates vomiting may result in the development of a Mallory-Weiss tear, which develops as a linear laceration at the gastroesophageal junction because the esophagus and stomach are cylindrical. The cylindrical shape allows longitudinal tears to occur more easily than circumferential tears. These tears have been postulated to occur either by a rapid increase in intragastric pressure and distention, which increases the forceful fluid ejection through the esophagus, or secondary to a significant change in transgastric pressure (ie, difference in pressure across the gastric wall) because negative intrathoracic pressure and positive intragastric pressure leads to distortion of the gastric cardia, resulting in a gastric or esophageal tear. Aside from those patients who present with upper GI bleeding secondary to an alcohol binge, Mallory-Weiss tears occur more commonly in people with hiatal hernias.

Although most cases of Mallory-Weiss tears are self-limiting, patients with severe or recurrent episodes of bleeding that require intensive care therapy and interventional endoscopy have been reported. Typically these patients have underlying conditions, including portal hypertension and hepatic insufficiency. Although upper GI bleeding is generally assumed to be secondary to varices in these patients, the physician must also be aware of the potential for Mallory-Weiss tears.

Frequency

United States

Mallory-Weiss tears cause approximately 3-15% of all episodes of hematemesis in adults; however, these tears are less common in children (<5% of all upper GI bleeding episodes).

Mortality/Morbidity

The major complication of a Mallory-Weiss tear is bleeding.³ Patients present with variable bleeding, which can range from a few specks or streaks of blood mixed with mucus to copious amounts of fresh red blood. In adults, shock occurs in as many as 20% of patients bleeding from Mallory-Weiss tears who present to emergency departments; as many as 45% of patients develop postural hypotension. Indeed, studies have also shown that those patients who present clinically in shock are more likely to require intensive care management and interventional endoscopic procedures. Moreover, these patients are more likely to experience recurrent episodes of bleeding secondary to Mallory-Weiss tears.⁴

Although children rarely have hemodynamic instability secondary to upper GI bleeding associated with Mallory-Weiss tears, the risk for potential complication, including shock, must be underscored in patients with portal hypertension and hepatic insufficiency.

Sex

Mallory-Weiss tears are equally common among male and female children. These tears also occur with equal frequency in both sexes in adults, although they have different causes. In women of childbearing age, the most common cause of these tears is hyperemesis gravidarum, which usually occurs in the first trimester, causing severe persistent nausea and vomiting. Any adolescent female presenting with a Mallory-Weiss tear should be evaluated for pregnancy, as well as bulimia and anorexia nervosa. Furthermore, the potential for drug and alcohol ingestion must also be underscored in the adolescent patient.

Age

Mallory-Weiss tears usually occur in the fifth and sixth decades of life. In children, tears are more commonly observed in older children and adolescents secondary to increased intragastric and transgastric pressures that develop at an older age. However, children with underlying medical conditions, including gastroesophageal reflux and liver disease, can present at any age.

Clinical

History

Presenting symptoms of Mallory-Weiss syndrome include hematemesis, melena, light-headedness, dizziness, syncope, and abdominal pain.

• Hematemesis: Hematemesis is the presenting symptom in all patients diagnosed with a Mallory-Weiss tear.⁵ The diagnosis does not depend on the amount of hematemesis because it can vary from blood flecks or streaks of blood mixed with gastric contents or mucus to several ounces of bright red bloody emesis. In most children, hematemesis is preceded by one or more episodes of nonbloody emesis; however, hematemesis secondary to a Mallory-Weiss tear has been reported to occur during the first bout of vomiting.
• Melena: Melena has been reported to occur in as many as 10% of patients who have been diagnosed with a Mallory-Weiss tear.
• Light-headedness, dizziness, or syncope: Patients with severe vomiting can develop light-headedness or dizziness. These symptoms usually occur secondary to dehydration from the underlying cause of vomiting and are not secondary to blood loss from the Mallory-Weiss tear. Only in rare cases does a Mallory-Weiss tear lead to anemia requiring transfusions.
• Abdominal pain, dyspepsia: As many as 40% of patients may experience epigastric pain or symptoms of heartburn. These symptoms are often related to the underlying cause of vomiting and not specifically to the Mallory-Weiss tear.

Physical

• No specific physical findings can be linked to the diagnosis of a Mallory-Weiss tear. Physical findings are linked to the underlying disorder causing the vomiting and retching.

Causes

Many underlying disorders that cause vomiting and retching result in a Mallory-Weiss tear.

• GI disease
  • Infectious gastroenteritis
  • Gastric outlet obstruction
  • Ulcers
  • Hiatal hernias
  • Malrotation
  • Volvulus
  • Inflammatory conditions of the stomach and intestine
• Pregnancy: Some women develop hyperemesis gravidarum, a syndrome characterized by persistent severe vomiting and retching, in the first trimester of pregnancy. Gastric dysrhythmias and prolonged small-bowel motility cause the development of hyperemesis gravidarum. Some women lose as much as 10% of their body weight during this period.
• Hepatitis: Acute inflammation of the liver causes vomiting in 10-20% of patients.
• Cirrhosis
• Biliary tract disease: Although rare in children, these conditions can cause vomiting typically associated with meals.
  • Gallstones
  • Cholecystitis
  • Biliary cirrhosis
• Renal disease: Vomiting is often associated with diseases affecting the kidneys, including the following:
  • Urinary tract infections
  • Kidney stones
  • Uteropelvic junction (UPJ) obstruction
  • Renal failure
• Increased intracranial pressure: Intracranial lesions that cause hydrocephalus or increased intracranial pressure may lead to vomiting in children. Most common causes of hydrocephalus include tumors, cysts, and congenital abnormalities. Other causes of increased intracranial pressure consist of trauma, infections (eg, meningitis), medications, and pseudotumor cerebri.
• Iatrogenic causes: Complications of endoscopy may cause esophageal tears (<0.01% in children) and are almost always associated with a patient who is retching or struggling during the procedure. The use of polyethylene glycol lavage, when used for ingestions, severe constipation, or preparation for colonoscopy, may cause severe vomiting.
• Other causes
  • Severe diabetic ketoacidosis
  • Toxins
  • Drugs (eg, chemotherapeutic agents)
• Cyclic vomiting syndrome

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