​Emergency and Acute Medicine – Mallory–Weiss Syndrome
​Basics description
Mallory–Weiss syndrome is a partial-thickness, longitudinal mucosal tear of the distal esophagus or proximal stomach. It results from a sudden increase in intra-abdominal or transgastric pressure, leading to mild to moderate submucosal arterial or venous bleeding. Endoscopic observations suggest that transient “mushrooming” of the stomach into the esophagus during forceful retching contributes to tear formation. It accounts for approximately 5% of all cases of upper gastrointestinal bleeding.
Etiology and risk factors
The condition is most commonly associated with forceful vomiting or retching but may also occur with coughing, laughing, lifting, straining, blunt abdominal trauma, seizures, childbirth, or cardiopulmonary resuscitation. Alcohol use, particularly following binge drinking, and the presence of a hiatal hernia are significant risk factors. More severe bleeding is seen in patients with portal hypertension, esophageal varices, or underlying coagulopathy.
Diagnosis signs and symptoms
Patients typically report multiple episodes of nonbloody vomiting or retching followed by hematemesis. Most bleeding is self-limited, though severe or life-threatening hemorrhage can occur. Associated symptoms include epigastric or back pain and signs of volume depletion such as dizziness, light-headedness, or syncope. Physical examination may reveal hematemesis, melena, postural hypotension, or shock in severe cases.
Essential workup and diagnostic testing
Initial evaluation includes a complete blood count and rectal examination for occult blood. Additional laboratory studies include coagulation parameters, electrolytes, renal function tests, liver function tests, and type and cross-match if bleeding is significant. Upright chest radiography may be obtained to exclude esophageal or gastric perforation. Upper endoscopy is the diagnostic and therapeutic modality of choice, allowing direct visualization and management of the bleeding source.
Differential diagnosis
Conditions to consider include nasopharyngeal bleeding, hemoptysis, esophageal rupture (Boerhaave syndrome), esophagitis, gastritis, peptic ulcer disease, variceal bleeding, malignancy, and vascular-enteric fistula.
Treatment and emergency management
Initial management focuses on airway protection, oxygenation, and hemodynamic stabilization with large-bore intravenous access and fluid resuscitation. Blood transfusion is indicated for ongoing bleeding or hemodynamic instability. Most cases resolve with conservative therapy. Persistent or active bleeding requires urgent endoscopic intervention, which may include injection therapy, thermal coagulation, clipping, or band ligation. Proton pump inhibitors and antiemetics are used adjunctively. Surgical or angiographic intervention is reserved for refractory cases.
Disposition and follow-up
Patients with ongoing or massive hemorrhage, hemodynamic instability, significant comorbidities, or advanced age require ICU admission. Stable patients with minimal bleeding that has resolved and stable hematocrit may be admitted for observation or, in select cases, discharged with close follow-up and outpatient endoscopy.
Key points and cautions
Early placement of large-bore intravenous access and prompt resuscitation are critical in upper gastrointestinal bleeding. Early gastroenterology consultation is essential when bleeding is significant. Rebleeding most often occurs within the first 24 hours and is more likely in patients with coagulopathy or portal hypertension.