Definition and Overview
Mallory-Weiss syndrome is a condition characterised by a tear in the mucus membrane located in the lower portion of the oesophagus. The laceration is usually linear and occurs at the junction where the oesophagus joins with the stomach. The tear is prone to bleeding and accounts for 5% of upper gastrointestinal haemorrhage. Up to 80% of patients have only one tear, which is usually 2-3 cm long and a few millimetres wide. A Mallory-Weiss tear usually involves both the mucosa and submucosa, but the muscular layer is not affected. If the muscular layer is also affected, the condition is called Boerhaave syndrome.
The condition, which is also called gastro-oesophageal laceration syndrome and syndrome de Mallory-Weiss, was first identified in 15 alcoholic patients by G. Kenneth Mallory and Soma Weiss in 1929. It is considered an oesophageal and swallowing disorder.
Causes of Condition
A Mallory-Weiss tear can occur due to either forceful or chronic severe coughing or vomiting, as well as hiccupping and straining. These are usually associated with the following conditions or circumstances:
Eating disorders, such as bulimia
Hyperemesis gravidarum, or severe morning sickness that causes vomiting and retching in pregnancy
Although the condition was first believed to be caused solely by alcoholic binging, later studies and the use of endoscopy showed that the condition also occurs in patients with no history of alcohol intake.
The tear can occur either after continuous vomiting and retching or after a single severe episode or incident of increased intragastric pressure. It can also occur after a violent prolapse of the upper stomach into the oesophagus.
Some evidence also suggests that having a hiatal hernia and the excessive use of nonsteroidal anti-inflammatory drugs (NSAID) can increase a person’s risk of suffering from the condition. Studies show that excessive aspirin use was reported in as much as 30% of patients with Mallory-Weiss tears.
Additionally, the condition can also be caused by blunt abdominal trauma, cardiopulmonary resuscitation, or primal scream therapy. However, in 25% of cases, there are no risk or precipitating factors identified.
The condition can affect all age groups. However, it is much more common in elderly men aged over 60 years old. Women with a Mallory Weiss or an oesophagus tear should automatically be evaluated for pregnancy, bulimia, or anorexia nervosa. The condition can also occur in children, especially those with predisposing conditions such as portal hypertension or severe gastroesophageal disease.
Symptoms of Mallory-Weiss syndrome are the following:
Bright red blood in vomit (haematemesis), which occurs in 85% of patients
Bloody stools (melena)
Hematochezia, or passage of fresh blood through the anus
Patients who experience the above symptoms should see a doctor for a diagnosis. They usually need to undergo diagnostic tests including a complete blood count (CBC) to determine whether they have low haematocrit levels, an indicator of a tear in the oesophagus. Doctors also monitor their platelet count, prothrombin time, activated partial thromboplastin time, and blood urea nitrogen, creatinine, and electrolyte levels.
However, a definitive diagnosis requires esophagogastroduodenoscopy (EGD), or the endoscopic examination of the lining of the oesophagus and the stomach. It is performed urgently to prevent severe haemorrhage in cases where there is active bleeding.
During an EGD, the doctor inserts a scope through the oesophagus and down into the stomach and duodenum. The scope allows the doctor to see inside the oesophagus and stomach without the need for open surgery. The patient is usually given a local anaesthetic and medicine to help him relax during the procedure, which lasts anywhere between 5 and 20 minutes.
Who to See and Types of Treatments Available
Patients can consult their general physician or family doctor for an initial diagnosis. Since the condition usually resolves on its own within a few days, Mallory-Weiss syndrome treatment often only involves medications, such as H2 blockers or proton pump inhibitors to suppress stomach acid. However, if the problem is chronic, the doctor can refer the patient to an endoscopy specialist for an EGD, during which the tear may be fixed with clips.
The most severe complication of a Mallory-Weiss syndrome is excessive bleeding. In cases where bleeding is severe, the patient may require cauterisation or an epinephrine injection during an EGD to stop the bleeding. If the patient has lost a lot of blood, he may also require blood transfusion.
Severe bleeding affects about 10% of patients with a Mallory-Weiss tear. When left untreated, this can cause shock and postural hypotension.
Surgical treatment of Mallory-Weiss syndrome is rarely necessary. Surgery is only used if the bleeding is severe and other methods to stop it are unsuccessful. In such cases, doctors may perform an embolisation of the arteries that supply blood to the region or a high gastrostomy, which ligates the bleeding vessel. Patients who experience severe blood loss should also be evaluated for myocardial ischemia especially if they have a pre-existing anaemia or cardiovascular disease. This can be done through a series of tests, such as an electrocardiogram, and by measuring cardiac enzymes.
The prognosis for patients who suffer from a Mallory-Weiss tear is quite good, as the tear usually heals without complications and bleeding stops permanently once the healing is complete.
Lynch KL. “Mallory Weiss Syndrome.” Merck Manual. http://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/mallory-weiss-syndrome
Cuffari C. “Mallory-Weiss Syndrome.” Medscape. http://emedicine.medscape.com/article/931141-overview#a6
Louis Michael Wong Kee Song. “Mallory Weiss Tear Overview of Mallory-Weiss Syndrome.” Jun 25 2015. Medscape. http://emedicine.medscape.com/article/187134-overview