Mallory-Weiss Tear

Risk factors

• Heavy alcohol use
• Hiatal hernia (present in 40-100% of cases)
• Severe vomiting from any cause: gastroenteritis, chemotherapy, bulimia, hyperemesis gravidarum
• Forceful coughing or seizures
• NSAID use, anticoagulation

Pathophysiology

An abrupt increase in intra-abdominal pressure during retching transmits to the lower esophagus, producing a longitudinal tear in the mucosa and submucosa just below or at the gastroesophageal junction. The tear does not extend through the muscular layer (distinguishing it from Boerhaave). Bleeding originates from submucosal arteries or venous plexus.

Clinical presentation

Differential diagnosis

• Peptic ulcer disease — Most common cause of upper GI bleeding; epigastric pain, melena, NSAID/H. pylori history; visible ulcer on EGD
• Esophageal or gastric varices — Cirrhosis or portal hypertension; larger volume bleed; treat with octreotide and band ligation
• Boerhaave syndrome — Full-thickness rupture; severe chest/abdominal pain, subcutaneous emphysema, mediastinitis; surgical emergency
• Erosive esophagitis or gastritis — Diffuse mucosal injury; lower volume blood loss; often related to NSAIDs, alcohol, severe illness
• Dieulafoy lesion — Submucosal arteriole; recurrent, often massive bleeding with negative initial endoscopy
• Malignancy (esophageal or gastric) — Weight loss, dysphagia, anemia, chronic blood loss; mass on endoscopy

Diagnostic workup

Diagnostic algorithm

flowchart TD
  A[Hematemesis after retching/vomiting] --> B[Resuscitate<br/>IVF, type and screen, PPI]
  B --> C{Hemodynamically stable?}
  C -->|No| D[Massive transfusion<br/>activate GI bleed protocol]
  C -->|Yes| E[Upright CXR<br/>rule out perforation]
  E --> F{Free air or<br/>pneumomediastinum?}
  F -->|Yes| G[Boerhaave concern<br/>CT + surgery consult]
  F -->|No| H[EGD within 24 h]
  H --> I{Active bleed or<br/>high-risk stigmata?}
  I -->|Yes| J[Endoscopic clip,<br/>band, or thermal +<br/>epinephrine]
  I -->|No| K[Observation<br/>PPI continued]
  J --> L[Refractory: angiographic<br/>embolization or surgery]

Treatment

Complications

• Rebleeding (rare, <10%)
• Hypovolemic shock if delayed presentation
• Aspiration pneumonia
• Rarely, progression to deeper tear or perforation (Boerhaave-like)

PANCE pearls

• Classic history: nonbloody vomiting followed by hematemesis in an alcohol user.
• Hiatal hernia is found in nearly all cases at endoscopy.
• Most Mallory-Weiss tears stop spontaneously — endoscopy is for diagnosis and risk stratification more than intervention.
• Always rule out Boerhaave with upright CXR if pain is severe or there are systemic signs.
• BUN/Cr ratio >30 in a bleeding patient strongly suggests an upper source from absorbed blood proteins.

References

• ACG 2021 — ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding (Laine et al., Am J Gastroenterol 2021)
• ASGE 2020 — ASGE guideline on the role of endoscopy in the management of acute non-variceal upper GI bleeding (Mullady et al., Gastrointest Endosc 2020)