Mallory-Weiss syndrome

Epidemiology

• Sex: ♂ > ♀ (3:1)

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Etiology

• Mechanism: a sudden and severe rise in the esophageal intraluminal pressure results in tearing of the esophageal mucous membrane, as well as the submucosal arteries and veins
• Precipitating factors
  • Severe vomiting
• Predisposing conditions
  • Alcohol use disorder
  • Bulimia nervosa
  • Hiatal hernia (higher pressure gradient)
  • Gastroesophageal reflux disease (GERD)

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Pathophysiology

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Clinical features

• May be asymptomatic
• Epigastric or back pain
• Hematemesis
  • typically follows a period of severe, bloodless vomiting
• Possible shock

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Diagnostics

EGD

• Typical findings
  • Often a single longitudinal tear (but multiple tears are possible) in the mucosa at the gastroesophageal junction or in the cardia of the stomach which are limited to the mucosa and submucosa
  • A fibrin crust over the split, a clot, or active bleeding may be evident.

Differential diagnostics

Feature	Mallory-Weiss Syndrome	Boerhaave Syndrome
Pathophysiology	Mucosal & submucosal tear at GEJ	Transmural rupture of distal esophagus
Presentation	Painless hematemesis post-vomiting/retching; epigastric pain	Severe retrosternal chest pain + fever, shock, subcutaneous emphysema (crepitus)
Key Associations	Alcohol use, bulimia	Alcohol abuse, overeating
Dx: Initial	EGD (visualizes linear tears)	CXR (pneumomediastinum, pleural effusion)
Dx: Best/Confirmatory	EGD	Gastrografin esophagogram (avoid barium/EGD)
Management	Supportive (IVF, PPIs, antiemetics); EGD w/ hemoclips/epi if active bleed	Emergent surgical repair + IV broad-spectrum Abx + NPO
Complications	Minimal (spontaneous resolution in 90%)	Mediastinitis, sepsis, empyema, high mortality

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Treatment

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