- 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 dissection) in the distal esophagus and proximal stomach, which are usually associated with forceful retching . The lacerations often lead to bleeding from submucosal arteries. This topic will review the epidemiology, pathogenesis, clinical manifestations, diagnosis, and management of Mallory-Weiss syndrome. The management of other causes of upper gastrointestinal bleeding and esophageal perforation are discussed in detail, separately. (See "Causes of upper gastrointestinal bleeding in adults" and "Boerhaave syndrome: Effort rupture of the esophagus".)
The reported incidence of Mallory-Weiss syndrome among patients presenting with upper gastrointestinal bleeding ranges from 8 to 15 percent [2-4]. It is likely that Mallory-Weiss syndrome occurs in a less severe form more frequently than is recognized. However, the incidence of Mallory-Weiss tear in patients without overt gastrointestinal bleeding is not well established [5,6].
ETIOLOGY AND PATHOGENESIS
The pathogenesis of Mallory-Weiss syndrome is not completely understood. It has been proposed that mucosal lacerations develop secondary to a sudden increase in intraabdominal pressure. Bleeding occurs when the tear involves the underlying esophageal venous or arterial plexus. Observational studies have identified certain clinical and demographic features as potential risk factors, although these are not all consistently found in all studies [4,7-15].
●Alcohol use— A history of heavy alcohol use leading to vomiting has been noted in 40 to 80 percent of patients with Mallory-Weiss syndrome in case series [4,8-11]. The bleeding is usually more severe when Mallory-Weiss tears are associated with portal hypertension and esophageal varices [12,13].
●Hiatal hernia — It is unclear if hiatal hernia is a risk factor for Mallory-Weiss syndrome. It has been proposed that retching increases the potential for mucosal laceration by creating a higher pressure gradient in the hiatus hernia as compared with the rest of the stomach. Although a hiatus hernia has been reported in 40 to 80 percent of patients with Mallory-Weiss tears in some case series, a large case-control study found no significant difference in the prevalence of hiatus hernia among patients with Mallory-Weiss syndrome and controls [8,14]. (See "Hiatus hernia".)
- 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. Miss rate of Mallory-Weiss tear after polyethylene glycol electrolyte lavage solution (abstract). Gastrointest Endosc 1998; 47:A51.
- Penston JG, Boyd EJ, Wormsley KG. Mallory-Weiss tears occurring during endoscopy: a report of seven cases. Endoscopy 1992; 24:262.
- 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.
- Corral JE, Keihanian T, Kröner PT, et al. Mallory Weiss syndrome is not associated with hiatal hernia: a matched case-control study. Scand J Gastroenterol 2017; 52:462.
- Cannon RA, Lee G, Cox KL. Gastrointestinal hemorrhage due to Mallory-Weiss syndrome in an infant. J Pediatr Gastroenterol Nutr 1985; 4:323.
- Fishman ML, Thirlwell MP, Daly DS. Mallory-Weiss tear. A complication of cancer chemotherapy. Cancer 1983; 52:2031.
- 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.
- Lee S, Ahn JY, Jung HY, et al. Effective endoscopic treatment of Mallory-Weiss syndrome using Glasgow-Blatchford score and Forrest classification. J Dig Dis 2016; 17:676.
- Banerjee S, Bellamkonda S, Gumaste VV. The Blatchford score is an useful index in the management of Mallory-Weiss tear and gastrointestinal bleeding: experience from an urban community hospital. Acta Gastroenterol Belg 2012; 75:432.
- Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010; 152:101.
- Laine L. Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage. A prospective controlled trial. N Engl J Med 1987; 316:1613.
- 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.
- 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.
- 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.
- 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.
- 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.
- Kovacs TO, Jensen DM. Endoscopic diagnosis and treatment of bleeding Mallory-Weiss tears. Gastrointest Endosc Clin North Am 1991; 1:387.
- 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.
- Bharucha AE, Gostout CJ, Balm RK. Clinical and endoscopic risk factors in the Mallory-Weiss syndrome. Am J Gastroenterol 1997; 92:805.
- Dill JE, Wells RF. Use of vasopressin in the Mallory-Weiss syndrome. N Engl J Med 1971; 284:852.
- 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.
- 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.
- ETIOLOGY AND PATHOGENESIS
- CLINICAL MANIFESTATIONS
- Upper endoscopy
- DIFFERENTIAL DIAGNOSIS
- INITIAL MANAGEMENT
- Inpatient versus outpatient management
- Pharmacologic therapy for all patients
- - Acid suppression
- - Antiemetics
- Endoscopic therapy for patients with active bleeding
- TREATMENT OF PERSISTENT AND RECURRENT BLEEDING
- RESUMPTION OF ANTICOAGULANTS AND ANTIPLATELET AGENTS
- SUMMARY AND RECOMMENDATIONS