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Mallory-Weiss syndrome

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamed Diab, MD [2]

Synonyms and keywords: Mallory-Weiss tear; Mucosal lacerations

Overview

Overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohamed Diab, MD [2]

Overview

Mallory-Weiss syndrome refers to bleeding from tears in the mucosa at the junction of the stomach and esophagus, usually caused by severe retching, coughing, or vomiting. It is often associated with alcoholism and eating disorders and there is some evidence that presence of a hiatal hernia is a required predisposing condition.

Historical Perspective

In 1929 G. Kenneth Mallory, pathologist (1900-86) and Soma Weiss, physician (1898-1942), first described Mallory-Weiss syndrome. [1].

Classification

There is no established system for the classification of Mallory-Weiss syndrome.

Pathophysiology

It is thought that Mallory-Weiss syndrome is the result of sudden increase in intraabdominal pressure that causes mucosal lacerations. If the tear involves the esophageal venous or arterial Plexus,bleeding occurs.

Causes

Mallory-Weiss syndrome is caused by severe retching, coughing, or vomiting. It is often associated with alcoholism and eating disorders and there is some evidence that presence of a hiatal hernia is a required predisposing condition.

Differentiating Mallory-Weiss syndrome overview from Other Diseases

Mallory-Weiss syndrome must be differentiated from other causes of Upper gastrointestinal bleeding such as PUD, Esophagogastric varices, Severe or erosive gastritis/duodenitis, Angiodysplasia.

Epidemiology and Demographics

Mallory-Weiss syndrome is suggested to be associated with increased age. The incidence of Mallory-Weiss syndrome is 4 per 100,000 individuals. The incidence of Mallory-Weiss syndrome in patients with Upper gastrointestinal bleeding is from 8% to 15%.

Risk Factors

The most potent risk factors in the development of Mallory-Weiss syndrome are Alcohol use and Hiatal hernia. The less potent risk factor in the development of Mallory-Weiss syndrome is age.

Screening

There is insufficient evidence to recommend routine screening for Mallory-Weiss syndrome.

Natural History, Complications, and Prognosis

Natural History

Mallory-Weiss tears heal quickly in the absence of portal hypertensive.

Complications

Hemorrhage, organ ischemia and infarction.

Prognosis

Repeated bleeding is uncommon and the outcome is usually good. Cirrhosis of the liver and problems with blood clotting make future bleeding episodes more likely to occur.

Diagnosis

History and Symptoms

The hallmark of Mallory-Weiss syndrome is acute onset of bloody vomiting. A positive history of forceful vomiting and retching are suggestive of Mallory-Weiss syndrome, but may present as an old blood in the stool with no history of retching.

Physical Examination

Mallory-Weiss syndrome is usually associated with tachycardia, weak pulse and hypotension.

Laboratory Findings

Blood tests, such as a complete blood count (CBC), blood chemistries, blood clotting tests, and liver function tests, are used to assess the condition of the patient.

BUN, creatinine, and electrolyte levels are measured to guide intravenous fluid therapy.

Imaging Findings

If there is mucosal laceration without perforation, it is likely to be occult on CT scan. However, CT may show evidence of hemorrhage or extraluminal gas at the tear site.

Other Diagnostic Studies

Upper endoscopy is the definitive diagnostic study for Mallory-Weiss Syndrome. Tears are located in the esophagogastric junction. The tear usually extends into the cardia and sometimes into the esophagus.

Treatment

Medical Therapy

Treatment of Mallory-Weiss syndrome is usually supportive because persistent bleeding is uncommon. Injection of epinephrine or cauterization may be done to stop bleeding during endoscopy.

Surgery

Surgical oversewing of the tear is reserved for those who fail angiographic therapy.

Prevention

Treatments to relieve vomiting and coughing may reduce risk. Avoidance of excessive alcohol use.

References

  1. ↑ Weiss S, Mallory GK. Lesions of the cardiac orifice of the stomach produced by vomiting. Journal of the American Medical Association 1932;98:1353-55.


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Historical Perspective

Historical Perspective

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohamed Diab, MD [2]

Overview

Mallory-Weiss syndrome was first described in 1929 by G. Kenneth Mallory and Soma Weiss in 15 alcoholic patients. [1]

Historical Perspective

  • In 1929 G. Kenneth Mallory, pathologist (1900-86) and Soma Weiss, physician (1898-1942), first described Mallory-Weiss syndrome. Initially it was thought it was associated with Alcoholism.However, with the development of medicine and the invention endoscopy the syndrome has been diagnosed in many patients with no history of alcohol consumption.[2]
  • The tear typically occurs after multiple episodes of vomiting or retching, but it may happen after one episode.
  • Mallory-Weiss syndrome may have become more common in recently. [3]

References

  1. ↑ Weiss S, Mallory GK. Lesions of the cardiac orifice of the stomach produced by vomiting. Journal of the American Medical Association 1932;98:1353-55.
  2. ↑ Graham DY, Schwartz JT (1978). “The spectrum of the Mallory-Weiss tear”. Medicine (Baltimore). 57 (4): 307–18. PMID 307105.
  3. ↑ Henrion J, Schapira M, Ghilain JM, Maisin JM, De maeght S, Deltenre P, Moulart M, Delaunoit T (2008). “Upper gastrointestinal bleeding: what has changed during the last 20 years?”. Gastroenterol. Clin. Biol. 32 (10): 839–47. doi:10.1016/j.gcb.2008.04.037. PMID 18786792.


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Classification

Classification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamed Diab, MD [2]

Overview

There is no established system for the classification of Mallory-Weiss syndrome.

Classification

There is no established system for the classification of Mallory-Weiss syndrome.

References

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Pathophysiology

Pathophysiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamed Diab, MD [2]

Overview

The exact pathogenesis of Mallory-Weiss syndrome is not fully understood. It is thought that Mallory-Weiss syndrome is the result of sudden increase in intraabdominal pressure that causes mucosal lacerations.

Pathogenesis

  • The exact pathogenesis of Mallory-Weiss syndrome is not fully understood.
  • It is thought that Mallory-Weiss syndrome is the result of sudden increase in intraabdominal pressure that causes mucosal lacerations. If the tear involves the esophageal venous or arterial Plexus,bleeding occurs.[1][2]

Genetics

There are no genes involved in the pathogenesis of Mallory-Weiss syndrome.

Gross Pathology

On gross pathology, Mallory-Weiss tears may appear red longitudinal break in the mucosa, sometimes may extend into muscularis mucosa, and covered by a clot. Active bleeding may also be observed.

References

  1. ↑ Byrne, John J.; Moran, John M. (1965). “The Mallory-Weiss Syndrome”. New England Journal of Medicine. 272 (8): 398–400. doi:10.1056/NEJM196502252720805. ISSN 0028-4793.
  2. ↑ Decker, John P.; Zamcheck, Norman; Mallory, G. Kenneth (1953). “Mallory-Weiss Syndrome”. New England Journal of Medicine. 249 (24): 957–963. doi:10.1056/NEJM195312102492401. ISSN 0028-4793.


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Causes

Causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamed Diab, MD [2]

Overview

Mallory-Weiss syndrome is caused by severe retching, coughing, or vomiting. It is often associated with alcoholism and eating disorders and there is some evidence that presence of a hiatal hernia is a required predisposing condition.

Causes

Life-threatening causes

Common causes [1]

Less common causes[2]

References

  1. ↑ Weaver DH, Maxwell JG, Castleton KB (1969). “Mallory-Weiss syndrome”. Am. J. Surg. 118 (6): 887–92. PMID 5358896.
  2. ↑ Shimoda R, Iwakiri R, Sakata H, Ogata S, Ootani H, Sakata Y, Fujise T, Yamaguchi K, Mannen K, Arima S, Shiraishi R, Noda T, Ono A, Tsunada S, Fujimoto K (2009). “Endoscopic hemostasis with metallic hemoclips for iatrogenic Mallory-Weiss tear caused by endoscopic examination”. Dig Endosc. 21 (1): 20–3. doi:10.1111/j.1443-1661.2008.00825.x. PMID 19691796.


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Differentiating Mallory-Weiss syndrome from other Diseases

Differentiating Mallory-Weiss syndrome from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamed Diab, MD [2]

Overview

Mallory-Weiss syndrome must be differentiated from other causes of Upper gastrointestinal bleeding such as PUD, Esophagogastric varices, Severe or erosive gastritis/duodenitis, Angiodysplasia.

Differential Diagnosis

Mallory-Weiss syndrome must be differentiated from other diseases that cause esophageal ulcers such as:[1]

Diseases History and Symptoms Physical Examination Laboratory Findings Upper endoscopy
Hematemesis Epigastric pain Light-headedness Retching Heartburn History of medication Vomiting History of alcoholism Tachycardia Skin Pallor Hypotension Weak pulse Hemoglobin Platelets BUN
Mallory-Weiss syndrome + + + (with heavy bleeding) + – – + + + (with heavy bleeding) + (with heavy bleeding) + (with heavy bleeding) + (with heavy bleeding) ↓ ↓ ↑ Tears are usually single and located in the esophagogastric junction, usually extends into the cardia and sometimes into the esophagus
Infectious esophagitis – + – – – – – – – – – – Ulcerations are multiple and usually involve the proximal esophagus
Medication-induced esophagitis – + – – – + – – – – – – Ulcerations are usually singular and deep
Reflux esophagitis – + – – + – – – – – – – Ulcerations are usually in distal esophagus, and maybe irregular and multiple

Mallory-Weiss syndrome must be differentiated from other causes of Upper gastrointestinal bleeding:[2][3][4][5]

Diseases History and Symptoms Physical Examination Laboratory Findings Upper endoscopy
Hematemesis Epigastric pain Retching History of alcoholism Light-headedness history of cirrhosis NSAIDs use Helicobacter pylori infection Tachycardia Hypotension Skin Pallor Weak pulse CBC Platelets BUN
Mallory-Weiss syndrome + + + + + – – – + (with heavy bleeding) + (with heavy bleeding) + (with heavy bleeding) + (with heavy bleeding) <math>\downarrow</math> <math>\downarrow</math> <math>\uparrow</math> Tears are usually single and located in the esophagogastric junction, usually extends into the cardia and sometimes into the esophagus
PUD +/- + – +/- – – + + + (with heavy bleeding) + (with heavy bleeding) + (with heavy bleeding) + (with heavy bleeding) <math>\downarrow</math> <math>\downarrow</math> <math>\uparrow</math> Discrete mucosal lesions with a punched-out smooth ulcer base with whitish fibrinoid base
Esophagogastric varices + + +/- + + – – + (with heavy bleeding) + (with heavy bleeding) + (with heavy bleeding) + (with heavy bleeding) <math>\downarrow</math> <math>\downarrow</math> <math>\uparrow</math> The varices may be in the esophagus and/or the stomach.
Severe or erosive gastritis/duodenitis + + +/- – – +/- – + (with heavy bleeding) + (with heavy bleeding) + (with heavy bleeding) + (with heavy bleeding) <math>\downarrow</math> <math>\downarrow</math> <math>\uparrow</math> Erythema, mucosal erosions, the absence of rugal folds, and visible vessels
Angiodysplasia + + – – +/- – – – + (with heavy bleeding) + (with heavy bleeding) + (with heavy bleeding) + (with heavy bleeding) <math>\downarrow</math> <math>\downarrow</math> <math>\uparrow</math> small, flat, cherry-red lesions with a fern-like pattern

References

  1. ↑ Sutton FM, Graham DY, Goodgame RW (1994). “Infectious esophagitis”. Gastrointest. Endosc. Clin. N. Am. 4 (4): 713–29. PMID 7812643.
  2. ↑ Boonpongmanee S, Fleischer DE, Pezzullo JC, Collier K, Mayoral W, Al-Kawas F, Chutkan R, Lewis JH, Tio TL, Benjamin SB (2004). “The frequency of peptic ulcer as a cause of upper-GI bleeding is exaggerated”. Gastrointest. Endosc. 59 (7): 788–94. PMID 15173790.
  3. ↑ Enestvedt BK, Gralnek IM, Mattek N, Lieberman DA, Eisen G (2008). “An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium”. Gastrointest. Endosc. 67 (3): 422–9. doi:10.1016/j.gie.2007.09.024. PMID 18206878.
  4. ↑ Balderas V, Bhore R, Lara LF, Spesivtseva J, Rockey DC (2011). “The hematocrit level in upper gastrointestinal hemorrhage: safety of endoscopy and outcomes”. Am. J. Med. 124 (10): 970–6. doi:10.1016/j.amjmed.2011.04.032. PMID 21962318.
  5. ↑ Wollenman CS, Chason R, Reisch JS, Rockey DC (2014). “Impact of ethnicity in upper gastrointestinal hemorrhage”. J. Clin. Gastroenterol. 48 (4): 343–50. doi:10.1097/MCG.0000000000000025. PMC 4157370. PMID 24275716.


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Epidemiology and Demographics

Epidemiology and Demographics

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamed Diab, MD [2]

Overview

Mallory-Weiss syndrome is suggested to be associated with increased age. The incidence of Mallory-Weiss syndrome is 4 per 100,000 individuals. The incidence of Mallory-Weiss syndrome in patients with Upper gastrointestinal bleeding is from 8% to 15%.[1][2][3]

Epidemiology and Demographics

Incidence

The incidence of Mallory-Weiss syndrome is 4 per 100,000 individuals.

The incidence of Mallory-Weiss syndrome in patients with Upper gastrointestinal bleeding is from 8% to 15%.[1][2][3]

Age

Mallory-Weiss syndrome is suggested to be associated with increased age.[4] However, most tears happen in patients younger than 40, which suggests that age doesn’t have a major role. Mallory-Weiss syndrome was also reported in infants. [5]

Gender

Mallory-Weiss syndrome occurs more in men than women by a ratio of 2-4:1.

References

  1. ↑ 1.0 1.1 Weaver DH, Maxwell JG, Castleton KB (1969). “Mallory-Weiss syndrome”. Am. J. Surg. 118 (6): 887–92. PMID 5358896.
  2. ↑ 2.0 2.1 Watts HD, Admirand WH (1974). “Mallory-Weiss syndrome. A reappraisal”. JAMA. 230 (12): 1674–5. PMID 4548094.
  3. ↑ 3.0 3.1 Michel L, Serrano A, Malt RA (1980). “Mallory-Weiss syndrome. Evolution of diagnostic and therapeutic patterns over two decades”. Ann. Surg. 192 (6): 716–21. PMC 1344969. PMID 7447523.
  4. ↑ Penston JG, Boyd EJ, Wormsley KG (1992). “Mallory-Weiss tears occurring during endoscopy: a report of seven cases”. Endoscopy. 24 (4): 262–5. doi:10.1055/s-2007-1009122. PMID 1366134.
  5. ↑ Cannon RA, Lee G, Cox KL (1985). “Gastrointestinal hemorrhage due to Mallory-Weiss syndrome in an infant”. J. Pediatr. Gastroenterol. Nutr. 4 (2): 323–4. PMID 3872935.


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Risk Factors

Risk Factors

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohamed Diab, MD [2]


Overview

The most potent risk factors in the development of Mallory-Weiss syndrome are Alcohol use and Hiatal hernia. The less potent risk factor in the development of Mallory-Weiss syndrome is age.

Common Risk Factors

  • Alcohol use: 40% to 80% of patients with Mallory-Weiss syndrome has a history of heavy alcohol use which lead to vomiting.[1][2][3][4][5]
  • Hiatal hernia: It is still unclear if it is a risk factor or not. It is reported in 40% to 80% of patients with Mallory-Weiss syndrome but big case-control study found no big difference in prevalence of hiatal

hernia between patients with Mallory-Weiss syndrome and controls.[2][6]

Less Common Risk Factors

  • Age: Mallory-Weiss syndrome is suggested to be associated with increased age.[7] However, most tears happen in patients younger than 40, which suggests that age doesn’t have a major role. Mallory-Weiss syndrome was also reported in infants. [8]

References

  1. ↑ Michel L, Serrano A, Malt RA (1980). “Mallory-Weiss syndrome. Evolution of diagnostic and therapeutic patterns over two decades”. Ann. Surg. 192 (6): 716–21. PMC 1344969. PMID 7447523.
  2. ↑ 2.0 2.1 Dagradi AE, Broderick JT, Juler G, Wolinsky S, Stempien SJ (1966). “The Mallory-Weiss syndrome and lesion. A study of 30 cases”. Am J Dig Dis. 11 (9): 710–21. PMID 5946360.
  3. ↑ Harris JM, DiPalma JA (1993). “Clinical significance of Mallory-Weiss tears”. Am. J. Gastroenterol. 88 (12): 2056–8. PMID 8249973.
  4. ↑ Knauer CM (1976). “Mallory-Weiss syndrome. Characterization of 75 Mallory-weiss lacerations in 528 patients with upper gastrointestinal hemorrhage”. Gastroenterology. 71 (1): 5–8. PMID 1084311.
  5. ↑ Sugawa C, Benishek D, Walt AJ (1983). “Mallory-Weiss syndrome. A study of 224 patients”. Am. J. Surg. 145 (1): 30–3. PMID 6600377.
  6. ↑ Corral JE, Keihanian T, Kröner PT, Dauer R, Lukens FJ, Sussman DA (2017). “Mallory Weiss syndrome is not associated with hiatal hernia: a matched case-control study”. Scand. J. Gastroenterol. 52 (4): 462–464. doi:10.1080/00365521.2016.1267793. PMID 28007004.
  7. ↑ Penston JG, Boyd EJ, Wormsley KG (1992). “Mallory-Weiss tears occurring during endoscopy: a report of seven cases”. Endoscopy. 24 (4): 262–5. doi:10.1055/s-2007-1009122. PMID 1366134.
  8. ↑ Cannon RA, Lee G, Cox KL (1985). “Gastrointestinal hemorrhage due to Mallory-Weiss syndrome in an infant”. J. Pediatr. Gastroenterol. Nutr. 4 (2): 323–4. PMID 3872935.


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Screening

Screening

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohamed Diab, MD [2]

Overview

There is insufficient evidence to recommend routine screening for Mallory-Weiss syndrome.

Screening

  • There is insufficient evidence to recommend routine screening for Mallory-Weiss syndrome.

References

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Natural History, Complications, and Prognosis

Natural History, Complications, and Prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohamed Diab, MD [2]

Overview

Mallory-Weiss tears heal quickly in the absence of portal hypertensive. Repeated bleeding is uncommon and the outcome is usually good. Cirrhosis of the liver and problems with blood clotting make future bleeding episodes more likely to occur.

Natural History

Mallory-Weiss tears heal quickly in the absence of portal hypertensive. Patients should be assessed for hemodynamic stability and determine the need for fluid resuscitation and/or blood transfusion.

Complications

Prognosis

  • Repeated bleeding is uncommon and the outcome is usually good. Cirrhosis of the liver and problems with blood clotting make future bleeding episodes more likely to occur.
  • Patients do not require repeat endoscopic evaluation to document healing.
  • Approximately 40% to 70% of patients with bleeding Mallory-Weiss syndrome require blood transfusions.[1][2]
  • The mortality rate is approximately 5% and depends on the age and the presence of coexisting medical conditions.

References

  1. ↑ De Vries AJ, van der Maaten JM, Laurens RR (2000). “Mallory-Weiss tear following cardiac surgery: transoesophageal echoprobe or nasogastric tube?”. Br J Anaesth. 84 (5): 646–9. PMID 10844847.
  2. ↑ Skok P (2003). “Fatal hemorrhage from a giant Mallory-Weiss tear”. Endoscopy. 35 (7): 635. doi:10.1055/s-2003-40214. PMID 12822109.


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Diagnosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | Electrocardiogram | X Ray | CT | MRI | Other Imaging Findings | Other Diagnostic Studies

Treatment

Treatment

Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Case Studies

Case Studies

Case #1

Related Chapters

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