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 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.

Mallory-Weiss tear with a pigmented protuberance and active oozing

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 MalloryWeiss 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.

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

Recommended Tests
Hematologic studies, chemistries, and type and screen are among laboratory studies performed to
evaluate patients 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.

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 predicting the 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) is 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.

ndoscopic 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 MalloryWeiss 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 20joule (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 tissuedamaging 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 thinwalled 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.

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 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.

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.

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 to
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 angiotherap