Overview of Mallory-Weiss Syndrome

Mallory-Weiss syndrome is characterized by upper gastrointestinal bleeding secondary to

longitudinal mucosal lacerations (known as Mallory-Weiss tears) 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. [1] However,
Mallory-Weiss syndrome may occur after any event that provokes a sudden rise in the
intragastric pressure or gastric prolapse into the esophagus, including antecedent transesophageal
echocardiography. [2]

Mallory-Weiss tears account for an estimated 1-15% of cases of upper gastrointestinal bleeding.
[3]
Although the age range varies widely, affected individuals are generally in middle age (40s-
50s), and men reportedly have a higher incidence than women by a ratio of 2-4:1.

The images below depict Mallory-Weiss tears.

Mallory-Weiss tear. Typical longitudinal

mucosal tear with overlying fibrinous exudate extending from the distal esophagus to the gastric cardia.
Courtesy of C.J. Gostout, MD.

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 Mallory-Weiss tear with a pigmented
protuberance and active oozing.

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Risk Factors for Mallory-Weiss Tears

Precipitating factors include retching, vomiting, straining, hiccupping, coughing, primal scream
therapy, blunt abdominal trauma, and cardiopulmonary resuscitation. In a few cases, no apparent
precipitating factor can be identified. One study reported that 25% of patients had no identifiable
risk factor.

The presence of a hiatal hernia is a predisposing factor and is found in 35-100% of patients with
Mallory-Weiss tears. [4] 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
(see Potential Mechanisms for Mallory-Weiss Tears).

Mallory-Weiss tears are usually associated with other mucosal lesions. In one study, 83% of
patients had additional mucosal abnormalities potentially contributing to bleeding or actually
causing retching and vomiting that would induce these tears.

Iatrogenic tears are uncommon, considering the frequency with which patients retch during
endoscopy. [5] The reported prevalence is 0.07-0.49%.

Mallory-Weiss tears associated with transesophageal echocardiography (TEE) (MWa) may be a

distinct clinical syndrome from Mallory Weiss tears not associated with TEE (MWu). [2] In a
review of the literature comprising 17 identified cases of MWa and a reported series of 73 cases
of MWu, Cappell et al noted that MWa patients had a significantly older mean age, greater rates
of concomitant anticoagulation, and higher mortality. [2]

Potential Mechanisms for Mallory-Weiss Tears

A Mallory-Weiss tear likely occurs as a result of a large, rapidly occurring, and transient
transmural pressure gradient across the region of the gastroesophageal junction. Acute distention
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. [6] 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 Mallory-Weiss tears is the violent prolapse or intussusception
of the upper stomach into the esophagus, as can be witnessed during forceful retching at
endoscopy.

Evaluation of Mallory-Weiss Tears

Hematemesis is present in 85% of patients. In fact, 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. [7] In a study by Harris and DiPalma, hematemesis on
first emesis was reported in 50% of patients. [8]

Less common presenting symptoms include melena, hematochezia, syncope, and abdominal
pain, and excessive alcohol use has been reported in 40-75% of patients, [9] and aspirin use has
been reported in up to 30% of patients [4] (see Risk Factors for Mallory-Weiss Tears).

Specific physical signs are generally not present for Mallory-Weiss tears. However, physical
findings relate to the rate and the degree of gastrointestinal blood loss. Tachycardia, hypotension,
orthostatic changes, or overt shock may be evident.

Diagnosis of Mallory-Weiss Tears

Perform endoscopy early in the clinical course; this technique is the procedure of choice for both
diagnosis and therapy of these lesions. Endoscopic diagnosis of a Mallory-Weiss tear is readily
made by identifying active bleeding, an adherent clot, or a fibrin crust over a mucosal split
within or near the gastroesophageal junction (see the following image).
 Mallory-Weiss tear. Typical longitudinal
mucosal tear with overlying fibrinous exudate extending from the distal esophagus to the gastric cardia.
Courtesy of C.J. Gostout, MD.

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When a Mallory-Weiss tear is suspected, also consider other conditions such as Boerhaave
syndrome, esophagitis, gastric ulcers and Cameron erosions.

Recommended tests

Hematologic studies, chemistries, and type and screen are among laboratory studies performed to
evaluate the patient's clinical statuses.

Obtain hemoglobin and hematocrit studies to assess the severity of the initial bleeding episode
and to monitor patients. In addition, platelet count, prothrombin time (PT), and activated partial
thromboplastin time (aPTT) are used to assess for severe thrombocytopenia and coagulopathy as
complicating issues. Coagulation studies are needed in patients on anticoagulants or with
minimal or no oral intake while on antibiotics. The platelet count may be low because of alcohol
use.

Blood urea nitrogen (BUN), creatinine, and electrolyte levels are measured to guide intravenous
fluid therapy, and blood type and antibody screen are obtained for potential blood transfusions.
Cardiac evaluation

Obtain an electrocardiogram and cardiac enzymes, if indicated, to assess for myocardial ischemia
related to acute gastrointestinal blood loss, especially in patients with significant anemia,
hemodynamic instability, cardiovascular disease, coexisting chest pain, and/or advanced age.

Endoscopy

Endoscopic diagnosis of a Mallory-Weiss tear is readily made by identifying active bleeding, an

adherent clot, or a fibrin crust over a mucosal split within or near the gastroesophageal junction.
On average, the split is 2-3 cm in length and a few millimeters in width. Most patients (>80%)
present with a single tear.

The usual location of the tear is just below the gastroesophageal junction on the lesser curvature
of the stomach (between 2 and 6 o'clock meridian on endoscopic viewing with the patient in the
left lateral decubitus position) (see the image below).

Mallory-Weiss tear. Retroflexed view of

the cardia showing the typical location of the tear with a clean base.

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Studies to avoid

Barium or Gastrografin studies should not be performed in patients with suspected Mallory-
Weiss tears owing to their low diagnostic sensitivity and interference with endoscopic
assessment and therapy.
Medical Management
Initial management of Mallory-Weiss tears consists of implementing resuscitative measures as
appropriate, performing endoscopy promptly, and triaging patients to intensive care, hospital
inpatient, or outpatient management, depending on the severity of bleeding, comorbidities, and
risk of rebleeding and complications.

Indications for inpatient versus outpatient treatment

Patients without risk factors for rebleeding (eg, portal hypertension, coagulopathy), severe
bleeding (eg, hematochezia, hemodynamic instability), or active bleeding at endoscopy can be
managed conservatively with an extended observation or brief hospitalization period
(approximately 24 h). [10] Patients with actively bleeding lesions should be hospitalized for at
least 48 hours. Patients with clinical risk factors for rebleeding (about 10% of cases) and
endoscopic stigmata of nonbleeding visible vessel, pigmented protuberance, or adherent clot
should be observed for 48 hours. If rebleeding occurs, it usually takes place within that time
period. In one study, the presence of shock at initial manifestation and active bleeding at
endoscopy were found to be independent risk factors for predicting recurrent bleeding in patients
with Mallory-Weiss tears. [11]

Initial management

Monitor the patients vital signs, obtain serial hemoglobin and hematocrit values (q6h initially),
watch for clinical signs of rebleeding, correct coagulopathy if possible, and maintain
hemodynamic support with fluid and blood replacement.

Control or eliminate precipitating factors, such as nausea and vomiting. Acid suppression (eg,
omeprazole) and antiemetic drug therapy (eg, prochlorperazine) are sufficient in most patients
presenting with a Mallory-Weiss tear.

Transfuse, generally, for hemoglobin levels less than 8 g/dL (< 10 g/dL for patients with
cardiopulmonary disease).

Five to 35% of patients require some form of intervention, mostly endoscopic. See specific
endoscopic therapy for actively bleeding Mallory-Weiss tears in Endoscopic Management. Treat
other associated lesions observed endoscopically, as appropriate.

Dietary constraints

Fasting is restricted to hemodynamically unstable patients and to those who require repeat
endoscopic intervention within a short time because of uncertainty regarding the effectiveness of
endoscopic therapy or possible complication of the initial therapy.

Unless nausea or vomiting is an issue, patients can resume oral intake following endoscopy,
starting with a clear- or full-liquid diet and advancing as tolerated to a regular diet within 48
hours.
Consultations

Consultation with an interventional vascular radiologist may be helpful to attempt angiotherapy

for bleeding that remains uncontrolled by endoscopic means (see Angiotherapy). Also obtain a
surgical consultation as surgery may be needed as salvage therapy for failed endoscopic and/or
radiologic intervention.

Endoscopic Management
Several endoscopic modalities are effective for treating a bleeding Mallory-Weiss tear. The
choice usually depends on the endoscopist's familiarity with a particular technique and on
equipment availability.

To treat or not to treat

Most patients have stopped bleeding at the time of endoscopy. Patients with actively bleeding
Mallory-Weiss tears (ie, arterial spurting, streaming from focal point, diffuse oozing) are treated.
Stigmata (eg, nonbleeding visible vessel, adherent clot) do not necessarily require treatment in
Mallory-Weiss tears as they do in peptic ulcers. Such stigmata are usually not treated unless they
are rebleeding episodes from the same lesion or are associated with a coagulopathy. [10, 11] Tears
with a clean, fibrinous base or with flat, pigmented spots are not treated, as the risk of rebleeding
is minimal.

Contact thermal treatment

A contact thermal modality, such as multipolar electrocoagulation (MPEC) or heater probe, with
or without epinephrine injection, is typically used to treat an actively bleeding Mallory-Weiss
tear. Effectiveness and safety have been established in only a few randomized, controlled trials.
For example, Laine demonstrated greater hemostatic efficacy, fewer emergency interventions,
and a trend toward decreased transfusion requirements in favor of MPEC versus sham MPEC. [12]

The MPEC or heater probe is applied on the bleeding point with mild to moderate pressure.
Suggested treatment parameters for MPEC include a power setting of 14-16 watts (W), 3-4
seconds per application, and 1-5 applications on average. Suggested treatment parameters for
heater probe include 15- to 20-joule (J) pulses in a sequence of 2-3 pulses. The endpoint is
cessation of bleeding and formation of a white coagulum.

Epinephrine injection

Epinephrine injection (1:10,000-1:20,000 dilution) reduces or stops bleeding via a mechanism of

vasoconstriction and tamponade. [13] This treatment is usually combined with a more definitive
therapy (eg, thermal therapy). Aliquots of 0.5-1 mL are injected around and into the bleeding
point. No ceiling volume has been identified, and as much as 20 mL of epinephrine have been
used. Careful monitoring is required, as submucosal esophageal injection of epinephrine may
enter the systemic circulation without a protective first-pass effect, potentially causing serious
cardiovascular complications. Epinephrine injection is best avoided in patients with active
cardiovascular disease.

Sclerosant injection

Successful use of sclerosants, such as alcohol or polidocanol, has been reported. [13, 14] Safer
alternatives exist, and sclerosant injection is not recommended by some authors because of its
potent tissue-damaging effects, risk of deep tissue necrosis, and potential for perforation.

Argon plasma coagulation

Reports on the use of the argon plasma coagulator (APC) in the treatment of bleeding Mallory-
Weiss tears are limited, but this noncontact device is gaining in popularity owing to its ease of
use. In the thin-walled esophagus, the power output should be set at 40-45 W and with a
relatively low argon gas flow rate (1 L/min). The APC probe should be maintained 1-2 mm from
the target site, which may be difficult to accomplish in the setting of peristalsis.

Band ligation

Endoscopic band ligation has been shown to be effective for treating bleeding Mallory-Weiss
tears. In a small, prospective, randomized study of 34 patients with actively bleeding lesions, no
difference was detected in the efficacy or safety of band ligation versus epinephrine injection. [15]
Band ligation should be particularly useful for bleeding Mallory-Weiss tears associated with
portal hypertension and gastroesophageal varices, in which thermal therapy is not recommended.

Hemoclip placement

Endoscopic hemoclip placement using the 2-pronged clip devices is also effective for Mallory-
Weiss tears. [16, 17] The margins of the tear may be approximated, starting at the distal end of the
tear and applying successive clips in a cephalad fashion. Alternatively, only the bleeding point
can be targeted for hemoclip placement.

Optimal deployment of clips may not be achievable because of the tangential location of the tear,
or the tear may be too wide. In a study of 26 patients, however, hemoclipping was technically
successful in all cases, and the average number of clips used was 2.8 + 1.6 (range, 1-8). [17] In a
randomized prospective study of 35 patients with actively bleeding lesions, hemoclip placement
and epinephrine injection were equally effective for achieving primary hemostasis. [16] Whenever
feasible, some authors favor the use of hemoclips over thermal modalities, as thermal modalities
may cause excessive tissue injury leading to necrosis and perforation. The recently introduced
over-the-scope clip (OTSC) device may also be useful for closure of a Mallory-Weiss tear, but
experience is limited with this device.
Balloon tamponade

Although earlier studies reported balloon tamponade to be beneficial, this technique should
probably be avoided, as it recreates the forces that predispose patients to lacerations and may
further widen the tear.

Angiotherapy
Angiotherapy with either selective vasopressin infusion or embolization of the left gastric artery
can be performed in patients whose lesions have failed to respond to endoscopic therapy or who
are at high risk of endoscopic complications. [18]

Surgical Management
Surgical oversewing of the tear is reserved for the occasional bleeding case that is refractory to
endoscopic therapy or angiotherapy.

Outpatient Monitoring
Watch for recurrent symptoms or signs of rebleeding. In addition, an acid suppressant (eg, proton
pump inhibitor; omeprazole, 20 mg PO qd) or a mucosal protectant (eg, sucralfate, 1 g PO qid) is
usually prescribed for 1-2 weeks to accelerate healing by reducing injurious factors, such as acid,
pepsin, or bile, that impair the healing of the mucosal tear. However, this practice is of unproven
benefit. An antiemetic (eg, prochlorperazine) is useful for controlling nausea and vomiting,
common precipitating factors for Mallory-Weiss tears.

Complications of Mallory-Weiss Tears

Complications, such as myocardial ischemia or infarction, [19] hypovolemic shock, and death,
usually relate to the acuity and the severity of bleeding and to associated comorbidities.
Fortunately, these complications are uncommon with the current standard of care.

Perforation or aggravation of bleeding during endoscopic therapy is a potential complication, and

organ ischemia and infarction are potential complications of angiotherapy.

Outcomes of Mallory-Weiss Tears

The prognosis of Mallory-Weiss tears is generally good. Bleeding from these lesions stops
spontaneously in 80-90% of patients. With conservative therapy, most tears heal uneventfully
within 48-72 hours. Thus, a Mallory-Weiss tear 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%. Currently, these figures are probably significantly lower.
Hemodynamic instability and shock may occur in up to 10% of patients with Mallory-Weiss
tears. In one series, mortality as high as 8.6% was attributed to these lesions; however, current
clinical experience suggests a significantly lower mortality rate from Mallory-Weiss tears.

In a prospective 5-year study (2005-2009), Ljubicic et al reported mortality rates in high-risk

patients with Mallory-Weiss syndrome were similar to those of patients with peptic ulcer
bleeding. [20] The investigators consecutively evaluated data from 281 patients with
endoscopically confirmed Mallory-Weiss syndrome and 1530 patients with peptic ulcer
bleeding. Significant prognostic factors for both conditions included age older than 65 years and
the presence of significant underlying comorbidities. [20]

Recurrence of these lesions is rare. However, counsel patients who have had a Mallory-Weiss
tear on precipitating factors (eg, alcoholic binge, excessive straining and lifting, violent
coughing) that may lead to a recurrent lesion (see Risk Factors for Mallory-Weiss Tears).

Special Considerations
Perform endoscopy promptly when indicated. Mallory-Weiss tears heal rapidly and may not be
readily apparent when endoscopically evaluated 2-3 days later. In addition, the endoscopic
examination should be thorough, as coexisting lesions are not uncommon. These lesions may be
actual or potential bleeding sites or precipitants of the Mallory-Weiss tear.