Mallory-Weiss Tear vs Boerhaave Syndrome
Mallory-Weiss Tear and Boerhaave Syndrome are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.
Mallory-Weiss Tear vs Boerhaave Syndrome at a glance
- Mallory-Weiss Tear: Longitudinal mucosal tear at the gastroesophageal junction following retching or vomiting, producing hematemesis.
- Boerhaave Syndrome: Spontaneous full-thickness esophageal rupture from forceful vomiting — high mortality, time-critical surgical emergency.
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Side-by-side comparison
| Feature | Mallory-Weiss Tear | Boerhaave Syndrome |
|---|---|---|
| At a glance | Longitudinal mucosal tear at the gastroesophageal junction following retching or vomiting, producing hematemesis. | Spontaneous full-thickness esophageal rupture from forceful vomiting — high mortality, time-critical surgical emergency. |
| Classic presentation | Hematemesis after nonbloody emesis is the textbook history.; Hematemesis (bright red or coffee-ground) following a bout of nonbloody vomiting or retching; Epigastric or retrosternal pain (less prominent than Boerhaave); Melena if bleeding is significant or delayed presentation; Lightheadedness, syncope if hemodynamically significant;… | Subcutaneous emphysema of the neck and chest in a patient with severe chest pain after vomiting is highly suggestive.; Sudden severe retrosternal, epigastric, or back pain immediately after forceful vomiting; Odynophagia, dysphagia; Dyspnea, tachypnea; Fever and signs of sepsis within hours if diagnosis delayed; Mackler triad: vomiting,… |
| Workup / key labs | Visualization of a longitudinal mucosal tear at the GE junction on EGD.; CBC, BMP, LFTs, coagulation studies, type and screen; BUN/Cr ratio (often elevated in upper GI bleed from absorbed blood); Lactate and lipase if clinical picture is unclear | Demonstration of extravasation of contrast from the esophagus, with extraluminal air or pleural communication on CT or esophagram.; CBC (leukocytosis), BMP, LFTs, lactate, coagulation studies, type and crossmatch; Blood cultures, pleural fluid analysis if effusion tapped (pH <6, elevated amylase from saliva) |
| Imaging | Upright CXR if any concern for perforation (free air, pneumomediastinum) — must exclude Boerhaave; Upper endoscopy (EGD) — diagnostic and therapeutic; performed within 24 h; CT chest/abdomen if EGD inconclusive or perforation suspected | Upright CXR — pneumomediastinum, subcutaneous emphysema, left pleural effusion, hydropneumothorax; CT chest with water-soluble oral contrast — preferred initial study; shows extraluminal air, fluid collections, perforation site; Water-soluble contrast (Gastrografin) esophagram — confirms perforation; barium reserved if Gastrografin… |
| First-line treatment | Supportive care: IV fluids, transfuse for hemoglobin <7 g/dL (or <8 if cardiovascular disease), correct coagulopathy; IV proton pump inhibitor: pantoprazole 80 mg bolus then 8 mg/h infusion, or intermittent dosing; Antiemetics: ondansetron or metoclopramide to prevent further retching; Most tears (80-90%) stop bleeding spontaneously and… | NPO, IV fluids, NG decompression (carefully, often under fluoroscopy); Broad-spectrum IV antibiotics: piperacillin-tazobactam, or carbapenem (meropenem); add antifungal (fluconazole) if immunocompromised or high suspicion of Candida; IV PPI (pantoprazole) to reduce gastric acid contamination; Surgical consultation immediately — primary… |
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