- Moises Guelrud, MD
Moises Guelrud, MD
- Clinical Professor of Medicine
- Tufts University School of Medicine
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 , 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 "Causes of upper gastrointestinal bleeding in adults" and "Boerhaave 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) . 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 . A Mallory-Weiss tear was found in 13 patients (1 percent); four developed active bleeding and nine were asymptomatic tears incidentally diagnosed during endoscopy.
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 . 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 . 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 . 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.
- Mallory GK, Weiss S. Hemorrhages from lacerations of the cardiac orifice of the stomach due to vomiting. Am J Med Sci 1929; 178:506.
- Weaver DH, Maxwell JG, Castleton KB. Mallory-Weiss syndrome. Am J Surg 1969; 118:887.
- Watts HD, Admirand WH. Mallory-Weiss syndrome. A reappraisal. JAMA 1974; 230:1674.
- Michel L, Serrano A, Malt RA. Mallory-Weiss syndrome. Evolution of diagnostic and therapeutic patterns over two decades. Ann Surg 1980; 192:716.
- Santoro MJ, Chen YK, Collen MJ. Polyethylene glycol electrolyte lavage solution-induced Mallory-Weiss tears. Am J Gastroenterol 1993; 88:1292.
- Guelrud M, Torres E, Vezga MA, et al. Miss rate of Mallory-Weiss tear after polyethylene glycol electrolyte lavage solution (abstract). Gastrointest Endosc 1998; 47:A51.
- Fishman ML, Thirlwell MP, Daly DS. Mallory-Weiss tear. A complication of cancer chemotherapy. Cancer 1983; 52:2031.
- Penston JG, Boyd EJ, Wormsley KG. Mallory-Weiss tears occurring during endoscopy: a report of seven cases. Endoscopy 1992; 24:262.
- Shimoda R, Iwakiri R, Sakata H, et al. Endoscopic hemostasis with metallic hemoclips for iatrogenic Mallory-Weiss tear caused by endoscopic examination. Dig Endosc 2009; 21:20.
- De Vries AJ, van der Maaten JM, Laurens RR. Mallory-Weiss tear following cardiac surgery: transoesophageal echoprobe or nasogastric tube? Br J Anaesth 2000; 84:646.
- Gilbert DA, Silverstein FE, Tedesco FJ. National ASGE survey on upper gastrointestinal bleeding: complications of endoscopy. Dig Dis Sci 1981; 26:55S.
- Dagradi AE, Broderick JT, Juler G, et al. The Mallory-Weiss syndrome and lesion. A study of 30 cases. Am J Dig Dis 1966; 11:710.
- Harris JM, DiPalma JA. Clinical significance of Mallory-Weiss tears. Am J Gastroenterol 1993; 88:2056.
- Knauer CM. Mallory-Weiss syndrome. Characterization of 75 Mallory-weiss lacerations in 528 patients with upper gastrointestinal hemorrhage. Gastroenterology 1976; 71:5.
- Sugawa C, Benishek D, Walt AJ. Mallory-Weiss syndrome. A study of 224 patients. Am J Surg 1983; 145:30.
- Paquet KJ, Mercado-Diaz M, Kalk JF. Frequency, significance and therapy of the Mallory-Weiss syndrome in patients with portal hypertension. Hepatology 1990; 11:879.
- Schuman BM, Threadgill ST. The influence of liver disease and portal hypertension on bleeding in Mallory-Weiss syndrome. J Clin Gastroenterol 1994; 18:10.
- Cannon RA, Lee G, Cox KL. Gastrointestinal hemorrhage due to Mallory-Weiss syndrome in an infant. J Pediatr Gastroenterol Nutr 1985; 4:323.
- Skok P. Fatal hemorrhage from a giant Mallory-Weiss tear. Endoscopy 2003; 35:635.
- Kortas DY, Haas LS, Simpson WG, et al. Mallory-Weiss tear: predisposing factors and predictors of a complicated course. Am J Gastroenterol 2001; 96:2863.
- Kovacs TO, Jensen DM. Endoscopic diagnosis and treatment of bleeding Mallory-Weiss tears. Gastrointest Endosc Clin North Am 1991; 1:387.
- Bharucha AE, Gostout CJ, Balm RK. Clinical and endoscopic risk factors in the Mallory-Weiss syndrome. Am J Gastroenterol 1997; 92:805.
- Bataller R, Llach J, Salmerón JM, et al. Endoscopic sclerotherapy in upper gastrointestinal bleeding due to the Mallory-Weiss syndrome. Am J Gastroenterol 1994; 89:2147.
- Sugawa C, Fujita Y, Ikeda T, Walt AJ. Endoscopic hemostasis of bleeding of the upper gastrointestinal tract by local injection of ninety-eight per cent dehydrated ethanol. Surg Gynecol Obstet 1986; 162:159.
- Llach J, Elizalde JI, Guevara MC, et al. Endoscopic injection therapy in bleeding Mallory-Weiss syndrome: a randomized controlled trial. Gastrointest Endosc 2001; 54:679.
- Laine L. Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage. A prospective controlled trial. N Engl J Med 1987; 316:1613.
- Wong RM, Ota S, Katoh A, et al. Endoscopic ligation for non-esophageal variceal upper gastrointestinal hemorrhage. Endoscopy 1998; 30:774.
- Abi-Hanna D, Williams SJ, Gillespie PE, Bourke MJ. Endoscopic band ligation for non-variceal non-ulcer gastrointestinal hemorrhage. Gastrointest Endosc 1998; 48:510.
- Matsui S, Kamisako T, Kudo M, Inoue R. Endoscopic band ligation for control of nonvariceal upper GI hemorrhage: comparison with bipolar electrocoagulation. Gastrointest Endosc 2002; 55:214.
- Park CH, Min SW, Sohn YH, et al. A prospective, randomized trial of endoscopic band ligation vs. epinephrine injection for actively bleeding Mallory-Weiss syndrome. Gastrointest Endosc 2004; 60:22.
- Yamaguchi Y, Yamato T, Katsumi N, et al. Endoscopic hemoclipping for upper GI bleeding due to Mallory-Weiss syndrome. Gastrointest Endosc 2001; 53:427.
- Yuan Y, Wang C, Hunt RH. Endoscopic clipping for acute nonvariceal upper-GI bleeding: a meta-analysis and critical appraisal of randomized controlled trials. Gastrointest Endosc 2008; 68:339.
- Huang SP, Wang HP, Lee YC, et al. Endoscopic hemoclip placement and epinephrine injection for Mallory-Weiss syndrome with active bleeding. Gastrointest Endosc 2002; 55:842.
- Cho YS, Chae HS, Kim HK, et al. Endoscopic band ligation and endoscopic hemoclip placement for patients with Mallory-Weiss syndrome and active bleeding. World J Gastroenterol 2008; 14:2080.
- Lecleire S, Antonietti M, Iwanicki-Caron I, et al. Endoscopic band ligation could decrease recurrent bleeding in Mallory-Weiss syndrome as compared to haemostasis by hemoclips plus epinephrine. Aliment Pharmacol Ther 2009; 30:399.
- Dill JE, Wells RF. Use of vasopressin in the Mallory-Weiss syndrome. N Engl J Med 1971; 284:852.
- Ljubičić N, Budimir I, Pavić T, et al. Mortality in high-risk patients with bleeding Mallory-Weiss syndrome is similar to that of peptic ulcer bleeding. Results of a prospective database study. Scand J Gastroenterol 2014; 49:458.