Mallory-Weiss tear

Background

Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.

Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.

Esophagus anatomy and nomenclature based on two systems.

• Longitudinal lacerations through mucosa and submucosa
• 75% in proximal stomach, rest in distal esophagus
• Due to sudden increase in intrabdominal pressure
  • Typically in the setting of forceful vomiting or retching

Clinical Features

Risk Factors

• Hiatal hernia
• Alcoholism
• Anything that increases intrabdominal pressure: blunt abdominal trauma, CPR, etc.

History

• Classic presentation: Hematemesis following vomiting or retching
  • As few as 30% of patients present this way
• Coffee ground emesis
• Melena
• Hematochezia

Differential Diagnosis

Upper gastrointestinal bleeding

• Peptic ulcer disease (most common cause)
  • Zollinger-Ellison syndrome
• Gastritis/esophagitis
• Gastric/esophageal varices
• Mallory-Weiss tear
• Malignancy
• Aortoenteric fisulta
• Boerhaave
• Dieulafoy's lesion
• Angiodysplasia
• Hemobilia
• Hemorrhagic gastritis, EtOH
• Celiac disease
• Dengue
• Other intrabdominal bleeds
  • Lower GI bleeding
  • Hemorrhagic pancreatitis
  • Splenic rupture
  • Subcapsular cavernous hemangiomas
  • Peliosis hepatis

Mimics of GI Bleeding

• Hemoptysis
• Vaginal/Urethra bleeding
• ENT bleeding
• Dietary (Iron, bismuth, beets)
• Swallowed maternal blood (in neonate)

Evaluation

Mallory–Weiss tear affecting the esophageal side of the gastroesophageal junction.

• Approach as any GI bleed
  • CBC
  • BMP
  • Type and screen
  • Guiac
  • CXR
• Definitive diagnosis by endoscopy

Management

• Most Mallory-Weiss tears are minor and resolve on their own, but up to 3% of upper gastrointestinal bleeding deaths are a result of Mallory-Weiss tears
• Endoscopy only for active and on-going bleeding
• Treat as undifferentiated upper GI bleed
  • Many of these patients are alcoholics and have cirrhosis; consider esophageal varices
  • History of vomiting/retching; consider boerhaave

Treatments Not Supported by the Literature

• No evidence to support octreotide use

Disposition

• Anticipate admission

See Also

• Gastrointestinal bleeding
• Upper gastrointestinal bleeding