Confusable diagnoses · PANCE / PANRE

Mallory-Weiss Tear vs Boerhaave Syndrome

Written & clinically reviewed by Ryan Busch, PA-C · Updated August 2026 · Report an error

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.

Try two board-style questions on Mallory-Weiss Tear vs Boerhaave Syndrome

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Question 1GastrointestinalMedium
A 52-year-old man with heavy alcohol use presents after vomiting bright red blood. Earlier that evening he had several bouts of forceful nonbloody retching, followed by hematemesis. He is hemodynamically stable with a soft, nontender abdomen and no chest pain or subcutaneous emphysema. Upright chest radiograph shows no free air or pneumomediastinum. Upper endoscopy reveals a longitudinal mucosal tear at the gastroesophageal junction with a hiatal hernia. Which of the following best explains the findings?
  • AElevated portal venous pressure dilating thin-walled submucosal veins
  • BAbrupt rise in transgastric pressure tearing the mucosa and submucosa
  • CAcid-peptic erosion eroding through the wall into a submucosal artery
  • DMucosal ischemia from splanchnic vasoconstriction during retching
Reveal answer & full explanation
Correct answer: B — Abrupt rise in transgastric pressure tearing the mucosa and submucosa
  • AElevated portal venous pressure dilating thin-walled submucosal veins
  • BAbrupt rise in transgastric pressure tearing the mucosa and submucosa✓
  • CAcid-peptic erosion eroding through the wall into a submucosal artery
  • DMucosal ischemia from splanchnic vasoconstriction during retching

Why Abrupt rise in transgastric pressure tearing the mucosa and submucosa is correct

  • A Mallory-Weiss tear results when forceful retching causes a sudden surge in intra-abdominal and transgastric pressure that is transmitted to the lower esophagus.
  • This produces a longitudinal laceration limited to the mucosa and submucosa at or just below the gastroesophageal junction; bleeding arises from submucosal arteries or the venous plexus.
  • A coexisting hiatal hernia (present in 40-100% of cases) is thought to predispose by allowing a greater pressure gradient across the GE junction.

Why the others are wrong

  • Elevated portal venous pressure dilating thin-walled submucosal veins describes esophageal varices, which cause larger-volume bleeds in cirrhosis or portal hypertension and appear as dilated venous columns, not a discrete linear tear, on EGD.
  • Acid-peptic erosion eroding through the wall into a submucosal artery describes peptic ulcer disease, the most common cause of upper GI bleeding, driven by acid with H. pylori or NSAIDs and seen as a discrete ulcer crater rather than a retching-induced tear.
  • Mucosal ischemia from splanchnic vasoconstriction during retching does not produce a discrete linear laceration: this patient is hemodynamically stable, and ischemic injury of the distal esophagus (acute esophageal necrosis) follows hypotension or a low-flow state and appears endoscopically as circumferential black mucosa.
Question 2GastrointestinalMedium
A 58-year-old man is brought to the emergency department after several episodes of forceful retching following a heavy alcohol binge. He developed sudden, severe retrosternal and left-sided chest pain immediately after the last episode of vomiting. He is tachycardic and febrile. On exam there is crepitus over the neck and a crunching sound on cardiac auscultation. CT of the chest with water-soluble oral contrast shows extraluminal contrast and air tracking through the mediastinum from a full-thickness defect in the distal esophagus. Which of the following best explains the findings?
  • AIntraluminal pressure rising against a closed sphincter beyond the esophageal wall strength
  • BEosinophil-driven transmural inflammation that progressively weakens the distal esophageal wall
  • CAcid reflux-induced columnar metaplasia with fibrotic stricturing of the distal esophageal wall
  • DInstrumental injury from recent endoscopic dilation weakening the distal esophageal wall
Reveal answer & full explanation
Correct answer: A — Intraluminal pressure rising against a closed sphincter beyond the esophageal wall strength
  • AIntraluminal pressure rising against a closed sphincter beyond the esophageal wall strength✓
  • BEosinophil-driven transmural inflammation that progressively weakens the distal esophageal wall
  • CAcid reflux-induced columnar metaplasia with fibrotic stricturing of the distal esophageal wall
  • DInstrumental injury from recent endoscopic dilation weakening the distal esophageal wall

Why Intraluminal pressure rising against a closed sphincter beyond the esophageal wall strength is correct

  • This is Boerhaave syndrome: forceful vomiting drives intraesophageal pressure up against a closed upper esophageal sphincter, and when that pressure exceeds the wall tensile strength a full-thickness transmural longitudinal tear results.
  • The rupture occurs in the left posterolateral distal third, where the wall is thinnest, allowing gastric contents to enter the mediastinum and pleural space and producing the pneumomediastinum, subcutaneous emphysema (crepitus), Hamman crunch, and mediastinitis seen here.

Why the others are wrong

  • Instrumental injury from recent endoscopic dilation weakening the distal esophageal wall — iatrogenic instrumentation is the most common overall cause of esophageal perforation, but this rupture began immediately after forceful retching with no endoscopy or dilation in the history, making barogenic transmural rupture the operative mechanism.
  • Eosinophil-driven transmural inflammation that progressively weakens the distal esophageal wall — this describes eosinophilic esophagitis, which causes dysphagia and food impaction and can predispose to perforation, but the acute event here is a pressure-driven rupture, not a primary inflammatory process.
  • Acid reflux-induced columnar metaplasia with fibrotic stricturing of the distal esophageal wall — this describes Barrett esophagus and peptic stricture, which are chronic complications of GERD rather than the acute barotraumatic mechanism causing this rupture.
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Side-by-side comparison

FeatureMallory-Weiss TearBoerhaave Syndrome
At a glanceLongitudinal 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 presentationHematemesis 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 labsVisualization 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 unclearDemonstration 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)
ImagingUpright 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 suspectedUpright 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 treatmentSupportive 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; a…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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Full outlines

Mallory-Weiss Tear Boerhaave Syndrome (Esophageal Perforation) All 514 diagnoses

Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.