Aetiology

MWT can be caused by: coughing, retching, vomiting, straining, hiccups, closed-chest pressure or cardiopulmonary resuscitation, acute abdominal blunt trauma, alcohol, chemotherapeutic agents, and oesophageal instrumentation.

Hiatal hernia is considered by many to be a key precipitating factor.[6][14][15] However, in >40% of patients an identifiable risk factor is not found.[13]

Conditions that may induce vomiting include:[11][16][17][18]

  • Gastrointestinal disease (e.g., food poisoning [particularly when due to Bacillus cereus, in which case vomiting occurs soon after ingestion of contaminated food], infectious gastroenteritis, peptic ulcer disease, malrotation, intussusception, volvulus, gastric outlet obstruction, and gastroparesis)

  • Hepatobiliary disease (e.g., hepatitis, gallstones, and cholecystitis)

  • Hyperemesis gravidarum

  • Renal disease (e.g., urinary tract infection, nephrolithiasis, renal failure, and ureteropelvic obstruction)

  • Neurological disease (e.g., tumours, hydrocephalus, congenital disease, trauma, meningitis, pseudotumour cerebri, migraine headaches, and seizures)

  • Psychiatric disease (e.g., anorexia nervosa, bulimia, and cyclic vomiting syndrome).

Other conditions or agents that may induce vomiting include:[19][20][21]

  • Toxins

  • Polyethylene glycol lavage (bowel preparation for colonoscopy)

  • Chemotherapy agents (e.g., cisplatin)

  • Post-anaesthesia or post-surgery.

A chronic cough may be associated with whooping cough, bronchitis, bronchiectasis, emphysema, chronic obstructive pulmonary disease, or lung cancer.[22]

Pathophysiology

The pathogenesis of MWT is not completely understood. Most cases seem to occur as a result of a sudden rise in abdominal pressure or transmural pressure gradient across the gastro-oesophageal junction with a corresponding low intrathoracic pressure. When these forces are high enough to cause distention in this area, an acute gastro-oesophageal tear or laceration may occur.

Classification

Number of lesions

MWT is generally classified by the number of lesions/tears:

  • Single tear

  • Multiple tears.

Endoscopic classification[3]

Proposed endoscopic classification according to endoscopic features of the tear.

  • Clean base

  • Non-bleeding adherent clot

  • Non-bleeding visible vessel (before or after clot removal)

  • Actively bleeding or spurting

  • Oesophageal rupture or perforation (Boerhaave's syndrome).

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