Mallory–Weiss syndrome

Overview

Mallory–Weiss syndrome (MWS) is a condition characterized by tears or lacerations in the mucosal lining of the lower esophagus or the upper part of the stomach (gastroesophageal junction). These tears result in bleeding, often presenting as hematemesis (vomiting blood). First described in 1929 by Drs. George Mallory and Soma Weiss, the syndrome is most commonly associated with episodes of forceful or repetitive vomiting, retching, or coughing that lead to increased intra-abdominal pressure and mucosal injury.

Although Mallory–Weiss tears can occur in any individual, they are more commonly seen in adults and individuals with chronic vomiting due to alcohol use, eating disorders, or gastrointestinal illness. In most cases, the condition resolves with conservative treatment, but severe bleeding may require endoscopic or surgical intervention.

Causes

Mallory–Weiss syndrome is primarily caused by a sudden increase in intra-abdominal pressure that results in tearing of the mucosa at the gastroesophageal junction. The most common causes and contributing factors include:

• Forceful vomiting or retching: Typically seen after excessive alcohol intake or gastrointestinal infections.

• Chronic alcohol abuse: A significant risk factor due to associated vomiting and mucosal irritation.

• Eating disorders: Such as bulimia nervosa, which involve repeated episodes of vomiting.

• Severe coughing or straining: Intense coughing bouts or physical exertion can also increase intra-abdominal pressure.

• Hiatal hernia: May predispose to mucosal weakness and tearing.

• Endoscopic procedures or blunt trauma: Rare iatrogenic causes.

While most cases are precipitated by identifiable events, spontaneous tears can occur, particularly in the elderly or those with underlying mucosal fragility.

Symptoms

The hallmark symptom of Mallory–Weiss syndrome is upper gastrointestinal bleeding. The severity can vary from minor oozing to significant hemorrhage. Common symptoms include:

• Hematemesis: Vomiting of bright red blood or coffee-ground-like material.

• Melena: Black, tarry stools indicating upper gastrointestinal bleeding.

• Epigastric pain or chest discomfort: Sometimes associated with retching episodes.

• Lightheadedness or dizziness: Especially in cases of significant blood loss.

• Fatigue or weakness: From anemia due to bleeding.

• Syncope (fainting): In rare cases of major hemorrhage.

Symptoms often follow an episode of vomiting or retching and can appear suddenly. In some patients, especially the elderly, bleeding may be occult and detected only through signs of anemia or hemodynamic instability.

Diagnosis

The diagnosis of Mallory–Weiss syndrome is typically confirmed through endoscopic evaluation. Diagnostic steps include:

• Patient history: Recent vomiting, retching, alcohol use, or GI symptoms are important clues.

• Physical examination: May reveal signs of hypovolemia such as pallor, rapid pulse, or low blood pressure.

• Laboratory tests:

  • Complete blood count (CBC) to assess hemoglobin and hematocrit levels

  • Blood urea nitrogen (BUN): Often elevated in upper GI bleeding

  • Coagulation profile: To assess for bleeding disorders

• Upper gastrointestinal endoscopy (esophagogastroduodenoscopy, EGD):

  • Gold standard for diagnosis

  • Reveals one or more longitudinal mucosal tears at the gastroesophageal junction

  • Also allows for therapeutic intervention if active bleeding is present

In cases where endoscopy is not immediately available, nasogastric lavage or imaging may provide preliminary evidence of upper GI bleeding.

Treatment

The treatment of Mallory–Weiss syndrome depends on the severity of bleeding. In most cases, the bleeding stops spontaneously and requires only supportive care. Treatment options include:

• Supportive care:

  • Intravenous fluids to maintain hydration and blood pressure

  • Blood transfusions if significant anemia or hemodynamic instability is present

  • Antiemetics to control nausea and prevent further vomiting

• Endoscopic therapy: Required if active bleeding persists or recurs.

  • Injection of epinephrine

  • Thermal coagulation (heater probe, argon plasma coagulation)

  • Hemostatic clipping

• Acid suppression therapy: Proton pump inhibitors (PPIs) are commonly used to promote mucosal healing.

• Surgery: Rarely needed, but may be necessary in cases of uncontrolled bleeding that fails to respond to endoscopic management.

Patients should also be advised to avoid alcohol and manage underlying risk factors to prevent recurrence.

Prognosis

The prognosis of Mallory–Weiss syndrome is generally excellent, especially in cases where bleeding stops spontaneously or is controlled with endoscopic intervention. Most patients recover fully without complications. However, certain factors can influence the outcome:

• Extent of bleeding: Massive hemorrhage can lead to hypovolemic shock and may require intensive care.

• Comorbid conditions: Chronic liver disease, coagulopathy, or cardiovascular disease can complicate recovery.

• Delayed diagnosis or treatment: Can lead to persistent bleeding or more severe anemia.

Recurrence is uncommon but can happen if precipitating factors, such as heavy alcohol use or recurrent vomiting, are not addressed. With appropriate care and lifestyle modifications, long-term outcomes are favorable.