Mallory-weiss tear

Introduction

A Mallory-Weiss tear is a longitudinal mucosal laceration at the gastro-oesophageal junction, typically caused by a sudden increase in intra-abdominal pressure. It is a recognised cause of upper gastrointestinal bleeding and often occurs following forceful vomiting, retching, or coughing.

Peak Incidence

• Most commonly affects adults between the ages of 50 and 60.

Pathophysiology

• A sudden rise in intra-abdominal pressure during events such as vomiting or retching causes a mucosal tear at the gastro-oesophageal junction.
• The tear is usually confined to the mucosa and submucosa.
• It may lead to bleeding from submucosal vessels.

Symptoms

• Haematemesis – Vomiting of fresh red blood or coffee-ground vomitus.
• Melaena – Black, tarry stools due to digested blood.
• Epigastric or upper abdominal pain – May occur before or during bleeding episodes.
• Dizziness or syncope – Due to volume depletion in more severe cases.

Signs

• Signs of shock may be present if bleeding is significant:
  • Hypotension.
  • Tachycardia.
  • Cold peripheries.
  • Pallor.

Diagnosis

• Clinical suspicion should be raised in patients presenting with upper GI bleeding and a history of:
  • Severe vomiting.
  • Retching.
  • Excessive alcohol intake.
• Oesophagogastroduodenoscopy (OGD) – Gold standard for diagnosis:
  • Visualises the longitudinal mucosal tear at the gastro-oesophageal junction.
  • Helps exclude other causes such as varices or peptic ulcers.
• Angiography – May be considered if:
  • Bleeding is ongoing and endoscopy is unsuccessful.
  • Can also serve a therapeutic purpose via embolisation.

Complications

• Recurrent bleeding.
• Hypovolaemic shock.
• Rarely, progression to full-thickness oesophageal rupture (i.e., Boerhaave syndrome).

Management

Initial Management (ABCDE Approach)

• Haemodynamic stabilisation:
  • Administer IV fluids and blood transfusions if needed.
• Pharmacological support:
  • Antiemetics (e.g., ondansetron) to prevent further vomiting.
  • Proton pump inhibitors (PPIs) (e.g., omeprazole or esomeprazole) to promote mucosal healing.
  • Reversal of anticoagulation if the patient is on warfarin or DOACs.

Definitive Management

• Endoscopic therapy (first-line):

  • Adrenaline injection to induce vasoconstriction and control bleeding.
  • Thermal coagulation (e.g., electrocoagulation).
  • Band ligation may be used in more severe cases.

• Angiographic embolisation:

  • Reserved for patients with ongoing bleeding where endoscopic therapy fails.

• Surgical intervention:

  • Very rarely required.
  • Considered only when both endoscopy and angiography are unsuccessful.