INTRODUCTION — 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 [1]. 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".)
EPIDEMIOLOGY — 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".)
●Age – Increasing age has been advocated as a predisposing factor of Mallory-Weiss tears [7]. However, most tears occur in patients under the age of 40, suggesting that age does not play a major role. Tears have also occurred in children as young as three weeks of age [15].
Precipitating factors include vomiting, straining or lifting, coughing, seizures, blunt abdominal injury, nasogastric tube placement, and gastroscopy [2-5,7,16-19].
CLINICAL MANIFESTATIONS — Patients usually present with acute onset of gastrointestinal bleeding with hematemesis (either red blood or coffee-ground emesis). Hematemesis may be accompanied by epigastric pain or pain in the back. Patients often have a history of nonbloody emesis, retching, or coughing prior to hematemesis [9]. Patients with significant bleeding may have signs of hypovolemia and hemodynamic instability (eg, resting tachycardia, hypotension).
DIAGNOSIS — Mallory-Weiss syndrome should be suspected in patients with upper gastrointestinal bleeding and a history of vomiting or retching. An upper endoscopy establishes the diagnosis, rules out other etiologies, and allows for therapeutic intervention.
Upper endoscopy — Mallory-Weiss tears are located in the esophagogastric junction, often within a hiatal hernia; they usually extend downward into the cardia and sometimes upward into the esophagus [10]. Mallory-Weiss tears are usually single and longitudinal. However, multiple mucosal tears have been found in up to 27 percent of cases [10,11]. On endoscopy, the tears typically appear as a red longitudinal break in the mucosa (picture 1), sometimes extending through the muscularis mucosa (picture 2), and occasionally covered by a clot (picture 3). Active bleeding may also be noted (picture 4). In many instances, the lesions are recognized only after retroflexion of the tip of the gastroscope to view the cardia from below. Most tears heal significantly within 24 to 48 hours in patients without portal hypertension and may be missed if endoscopy is delayed [20].
DIFFERENTIAL DIAGNOSIS — The differential diagnosis of Mallory-Weiss syndrome includes other diseases of the esophagus that causes esophageal ulcers (eg, reflux, medication and infections). Mallory-Weiss syndrome can be distinguished from these by history and upper endoscopy.
●Reflux esophagitis – Patients often have a history of heartburn (pyrosis), regurgitation, and dysphagia/odynophagia. The ulcerations seen in reflux esophagitis are usually in the distal esophagus, but unlike Mallory-Weiss tears, ulcers may be irregularly shaped and multiple. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults", section on 'Upper gastrointestinal endoscopy'.)
●Medication-induced esophagitis – Medication-induced esophagitis is suspected by the history (eg, use of a drug such as tetracycline or alendronate). Medication-induced ulcerations are usually singular and deep, occurring at points of stasis (especially near the carina), with sparing of the distal esophagus. (See "Pill esophagitis", section on 'Diagnostic evaluation'.)
●Infectious esophagitis – Infectious esophagitis is circumferential and tends to involve the proximal esophagus. Ulcers are multiple and punctate. In patients with herpes simplex virus esophagitis, ulcers in the distal esophagus are well circumscribed and have a "volcano-like" appearance. In patients with cytomegalovirus infection, ulcers tend to be linear or longitudinal and deep. The diagnosis of infectious esophagitis is established by biopsies or brushing ideally taken from the edge of an ulcer. (See "Herpes simplex virus infection of the esophagus", section on 'Diagnosis'.)
Other causes of upper gastrointestinal bleeding are discussed in detail separately. (See "Causes of upper gastrointestinal bleeding in adults", section on 'Specific causes'.)
INITIAL MANAGEMENT
Overview — The initial evaluation of a patient with upper gastrointestinal bleeding starts with assessing hemodynamic stability and determining the need for fluid resuscitation and/or blood transfusion. This part of the evaluation is discussed in detail elsewhere. (See "Approach to acute upper gastrointestinal bleeding in adults".)
Patients with clinically significant upper gastrointestinal bleeding (ie, signs of active upper gastrointestinal bleeding including hematemesis, melena, or hematochezia, with or without hemodynamic instability or blood transfusion requirement) should be started on a twice-daily intravenous (IV) proton pump inhibitor (PPI) prior to endoscopy as part of their initial management. (See "Approach to acute upper gastrointestinal bleeding in adults", section on 'Acid suppression'.)
Once the patient is stabilized, endoscopy is performed for diagnosis and potential treatment. Mallory-Weiss tears that are actively bleeding (spurting or oozing hemorrhage) require endoscopic therapy. Mallory-Weiss tears that are not actively bleeding can be managed with acid suppression alone. We reserve the use of antiemetics for patients with Mallory-Weiss syndrome who have persistent nausea or vomiting. (See 'Endoscopic therapy for patients with active bleeding' below and 'Acid suppression' below and 'Antiemetics' below.)
Inpatient versus outpatient management — We typically hospitalize and observe patients at high risk for rebleeding and its complications for a minimum of 48 hours. This includes patients with any one of the following:
●Risk factors for recurrent bleeding (active bleeding at the time of endoscopy, portal hypertension coagulopathy).
●Endoscopic stigmata of recent bleeding (eg, nonbleeding visible vessel or adherent clot).
●Severe upper gastrointestinal bleeding (hemodynamic instability, hematochezia, blood transfusion requirement).
●Increased risk for complications should bleeding recur (eg, significant coronary artery or cerebrovascular disease, age over 65 years, patients taking antiplatelet or anticoagulant medications).
Risk stratification scores can help differentiate patients who require hospitalization from those who are appropriate for outpatient management [21,22]. It is recommended in the International Consensus Recommendations that all patients with upper gastrointestinal bleeding undergo risk stratification using a validated prognostic scale such as the Rockall score (calculator 1), Blatchford score (calculator 2) or AIMS65 score [23]. (See "Approach to acute upper gastrointestinal bleeding in adults", section on 'Risk stratification'.)
Patients without risk factors for rebleeding, evidence of severe upper gastrointestinal bleeding, or endoscopic stigmata of recent bleeding can be discharged from the hospital on oral antisecretory therapy once the effects of procedural sedation have worn off, provided that the patient is reliable and can promptly get medical care should bleeding recur.
Pharmacologic therapy for all patients — Pharmacologic therapy for Mallory-Weiss syndrome includes acid suppression with PPI and antiemetics.
Acid suppression — In general, a twice-daily IV PPI should be given to all patients with suspected clinically significant upper gastrointestinal bleeding prior to endoscopy as part of their initial management. (See "Approach to acute upper gastrointestinal bleeding in adults", section on 'Acid suppression'.)
The twice-daily IV PPI may be switched to a standard-dose oral PPI (eg, omeprazole 20 mg daily) following endoscopy. We continue oral PPI therapy for two weeks to stabilize the clot and accelerate mucosal healing. PPIs may promote hemostasis by neutralizing gastric acid and stabilizing blood clots. However, the efficacy of PPI therapy for preventing rebleeding in Mallory-Weiss syndrome has not been well-studied. (See "Overview of the treatment of bleeding peptic ulcers", section on 'Efficacy of proton pump inhibitors'.)
Antiemetics — Antiemetics (eg, metoclopramide, prochlorperazine) are reserved for patients with persistent nausea or vomiting. (See "Approach to the adult with nausea and vomiting", section on 'Treatment'.)
Endoscopic therapy for patients with active bleeding — Endoscopic therapy is indicated for treatment of actively bleeding (spurting or oozing hemorrhage) Mallory-Weiss tears. Patients may be treated with thermal coagulation, endoscopic clips, or endoscopic band ligation (with or without epinephrine injection) but should not be treated with epinephrine monotherapy due to an increased risk of recurrent bleeding [17,24-32]. The choice between endoscopic clips, endoscopic band ligation, and thermal therapy will often depend upon the preference of the endoscopist and the presence of underlying portal hypertension or esophageal varices. In patients with portal hypertension or esophageal varices, endoscopic band ligation should be performed as thermal coagulation may precipitate or worsen bleeding.
The technique for thermal coagulation is generally similar to that used in patients with peptic ulcer bleeding. However, coagulation should be performed with less tamponade force and lower total energy (eg, bipolar probe at 15 watts, mild tamponade, and one second pulses) in patients with Mallory-Weiss syndrome as the esophagus lacks a serosa and may be very thin at the tear site and the underlying artery is small. Repeated coagulation should be avoided because of the risk of transmural injury and perforation [33]. The technique for endoscopic clips, endoscopic band ligation, and injection with epinephrine are similar to patients with peptic ulcer bleeding. Detailed discussions of the endoscopic techniques used for hemostasis are presented elsewhere. (See "Contact thermal devices for the treatment of bleeding peptic ulcers" and "Endoscopic clip therapy in the gastrointestinal tract: Bleeding lesions and beyond" and "Overview of the treatment of bleeding peptic ulcers", section on 'Injection therapy'.)
Few studies have directly compared these modalities [21,27,34]. In a randomized trial in which 41 patients with actively bleeding Mallory-Weiss tears were assigned to endoscopic band ligation or endoscopic clip placement, there were no differences in the rates of primary hemostasis or rebleeding between the two groups [34]. In a retrospective study that included 168 patients with Mallory-Weiss tear, endoscopic clip-based therapy and band ligation were associated with higher success rates in preventing rebleeding as compared with injection therapy alone (96, 89, and 71 percent, respectively) [21]. (See "Endoscopic variceal ligation".)
Injection of sclerosing agents (eg, ethanol, polidocanol) can be effective in achieving hemostasis in patients with Mallory-Weiss syndrome [33,35,36]. However, sclerosing agents are not widely used due to the risk of deep tissue necrosis and perforation.
TREATMENT OF PERSISTENT AND RECURRENT BLEEDING — The majority of patients with Mallory-Weiss syndrome can be controlled endoscopically. Approximately 7 percent have recurrent bleeding. Rebleeding in patients with Mallory-Weiss syndrome usually occurs within 24 hours of the initial episode [37]. If feasible, we perform a repeat upper endoscopy in patients with rebleeding.
We suggest that patients who have failed endoscopic therapy undergo attempted angiography with transarterial embolization (TAE), and that surgery with oversewing of the bleeding vessel be reserved for those who fail angiographic therapy [2,4,38]. However, surgery is a reasonable alternative if an interventional radiologist with expertise in TAE is not available, if the lesion is deemed unlikely to respond to angiographic therapy, or if the patient has underlying conditions that may complicate the ability to perform angiography or TAE (eg, renal insufficiency). (See "Angiographic control of nonvariceal gastrointestinal bleeding in adults".)
PROGNOSIS — Mallory-Weiss syndrome tears heal rapidly in the absence of portal hypertensive gastropathy. Patients do not require repeat endoscopic evaluation to document healing. Approximately 7 percent of patients have recurrent bleeding which usually occurs within 24 hours of the initial episode. Approximately 40 to 70 percent of patients with bleeding Mallory-Weiss syndrome require blood transfusions [18,39]. Active bleeding at the time of initial endoscopy and a low initial hematocrit have been associated with a higher rate of rebleeding, need for angiography or surgery, or death [40]. The mortality rate is approximately 5 percent and depends upon patient age and the presence of coexisting medical conditions. A retrospective study comparing the 30-day mortality in 281 patients with endoscopically confirmed Mallory-Weiss syndrome and 1530 patients with peptic ulcer bleeding found that the mortality rate was 5.3 percent for patients with bleeding Mallory-Weiss syndrome and 4.6 percent for patients with peptic ulcer bleeding [41]. In both patients with bleeding Mallory-Weiss syndrome and peptic ulcer bleeding, mortality was significantly higher in patients over 65 years of age and those with significant overall comorbidities.
RESUMPTION OF ANTICOAGULANTS AND ANTIPLATELET AGENTS — Data are limited with regard to the appropriate timing for resuming anticoagulation or antiplatelet agents following endoscopic hemostasis. The timing will depend on the patient's risk of suffering a thromboembolic event while off of the medication(s). When to resume these agents after hemostasis has been achieved is discussed elsewhere. (See "Management of anticoagulants in patients undergoing endoscopic procedures", section on 'Resuming anticoagulants after hemostasis' and "Management of antiplatelet agents in patients undergoing endoscopic procedures".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gastrointestinal bleeding in adults".)
SUMMARY AND RECOMMENDATIONS
●Mallory-Weiss syndrome is characterized by longitudinal mucosal lacerations (intramural dissections) in the distal esophagus and proximal stomach secondary to a sudden increase in intraabdominal pressure. Bleeding occurs when the tear involves the underlying esophageal venous or arterial plexus. Potential risk factors include alcohol use and hiatus hernia. Mallory-Weiss syndrome may be precipitated by vomiting, straining or lifting, coughing, seizures, blunt abdominal injury, nasogastric tube placement, and gastroscopy. (See 'Epidemiology' above and 'Etiology and pathogenesis' above.)
●Acute gastrointestinal bleeding is the major clinical manifestation of Mallory-Weiss syndrome and may be accompanied by epigastric pain or pain in the back. Patients often have a history of nonbloody vomiting or retching before the onset of hematemesis. (See 'Clinical manifestations' above.)
●The initial evaluation of the patient with upper gastrointestinal bleeding involves an assessment of hemodynamic stability and the necessity for fluid resuscitation. In general, a twice-daily intravenous proton pump inhibitor (PPI) is administered to all patients with suspected clinically significant upper gastrointestinal bleeding prior to endoscopy as part of their initial management. (See "Approach to acute upper gastrointestinal bleeding in adults", section on 'Acid suppression'.)
●The diagnosis of Mallory-Weiss syndrome should be suspected in patients with upper gastrointestinal bleeding and a history of vomiting or retching. An upper endoscopy establishes the diagnosis, rules out other etiologies, and allows for therapeutic intervention. (See 'Diagnosis' above.)
●In patients with active bleeding (oozing or spurting) from a Mallory-Weiss tear, we recommend endoscopic therapy and acid suppressive therapy rather than acid suppressive therapy alone (Grade 1B). Patients may be treated with thermal coagulation, endoscopic clips, or endoscopic band ligation (with or without epinephrine injection) but should not be treated with epinephrine monotherapy due to an increased risk of recurrent bleeding. Mallory-Weiss tears that are not actively bleeding at the time of endoscopy can be managed with acid suppression alone. We continue standard-dose oral PPI (eg, omeprazole 20 mg daily) therapy for two weeks. (See 'Overview' above and 'Acid suppression' above.)
●We typically hospitalize and observe patients at high risk for rebleeding and its complications for a minimum of 48 hours. This includes patients with any one of the following:
•Risk factors for recurrent bleeding (active bleeding at the time of endoscopy, portal hypertension, coagulopathy).
•Endoscopic stigmata of recent bleeding (eg, non-bleeding visible vessel or adherent clot).
•Severe upper gastrointestinal bleeding (hemodynamic instability, hematochezia, blood transfusion requirement).
•Increased risk for complications should bleeding recur (eg, significant coronary artery or cerebrovascular disease, age over 65 years, patients taking antiplatelet or anticoagulant medications).
●In patients without risk factors for rebleeding, endoscopic stigmata of recent bleeding or clinical features indicating severe bleeding, we suggest discharge following endoscopy on a standard-dose proton pump inhibitor rather than admission to the hospital for observation (Grade 2C). Almost all such patients will heal spontaneously. (See 'Inpatient versus outpatient management' above.)
●Approximately 7 percent of patients with Mallory–Weiss syndrome have recurrent bleeding. We suggest that patients who fail endoscopic therapy undergo transarterial angiographic embolization rather than surgery (Grade 2C). (See 'Treatment of persistent and recurrent bleeding' above.)
●Mallory-Weiss syndrome tears heal rapidly in the absence of portal hypertensive gastropathy. Patients do not require repeat endoscopic evaluation to document healing. Approximately 40 to 70 percent of patients with Mallory-Weiss syndrome require blood transfusions. The mortality rate is approximately 5 percent and depends upon patient age and the presence of coexisting medical conditions.
