Mallory-Weiss tear

Factors such as coughing, retching, vomiting, straining, hiccups, closed-chest pressure or cardiopulmonary resuscitation, acute abdominal blunt trauma, alcohol, medications (aspirin or other nonsteroidal anti-inflammatory drugs), chemotherapeutic agents, and esophageal instrumentation have been associated with MWT.

Hiatus hernia, which is present in 40% to 100% of people with MWT, is considered by many to be a precipitating factor, causing an esophageal tear to occur.[4]Michel L, Serrano A, Malt RA. Mallory-Weiss syndrome: evolution of diagnostic and therapeutic patterns over two decades. Ann Surg. 1980 Dec;192(6):716-21. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1344969 http://www.ncbi.nlm.nih.gov/pubmed/7447523?tool=bestpractice.com [15]Sato H, Takase S, Takada A. The association of esophageal hiatus hernia with Mallory-Weiss syndrome. Gastroenterol Jpn. 1989 Jun;24(3):233-8. http://www.ncbi.nlm.nih.gov/pubmed/2744343?tool=bestpractice.com [16]Caroli A, Follador R, Gobbi V, et al. Mallory-Weiss syndrome: personal experience and review of the literature [in Italian]. Minerva Dietol Gastroenterol. 1989 Jan-Mar;35(1):7-12. http://www.ncbi.nlm.nih.gov/pubmed/2657497?tool=bestpractice.com However, in >40% of patients an identifiable risk factor is not found.[14]Harris JM, DiPalma JA. Clinical significance of Mallory-Weiss tears. Am J Gastroenterol. 1993 Dec;88(12):2056-8. http://www.ncbi.nlm.nih.gov/pubmed/8249973?tool=bestpractice.com

Conditions that may induce vomiting include:[12]Ismail SK, Kenny L. Review on hyperemesis gravidarum. Best Pract Res Clin Gastroenterol. 2007;21(5):755-69. http://www.ncbi.nlm.nih.gov/pubmed/17889806?tool=bestpractice.com [17]Gowen GF, Stoldt HS, Rosato FE. Five risk factors identify patients with gastroesophageal intussusception. Arch Surg. 1999 Dec;134(12):1394-7. https://jamanetwork.com/journals/jamasurgery/fullarticle/390449 http://www.ncbi.nlm.nih.gov/pubmed/10593341?tool=bestpractice.com [18]Sansone RA. Complications of hazardous weight-loss methods. Am Fam Physician. 1984 Aug;30(2):141-6. http://www.ncbi.nlm.nih.gov/pubmed/6147075?tool=bestpractice.com [19]Mehler PS. Clinical practice: bulimia nervosa. N Engl J Med. 2003 Aug 28;349(9):875-81. http://www.ncbi.nlm.nih.gov/pubmed/12944574?tool=bestpractice.com

• Gastrointestinal disease (e.g., food poisoning [particularly when due to Bacillus cereus, 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)

• Neurologic disease (e.g., tumors, hydrocephalus, congenital disease, trauma, meningitis, pseudotumor 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:[20]Lichtenstein GR, Cohen LB, Uribarri J. Review article: bowel preparation for colonoscopy - the importance of adequate hydration. Aliment Pharmacol Ther. 2007 Sep 1;26(5):633-41. http://www.ncbi.nlm.nih.gov/pubmed/17697197?tool=bestpractice.com [21]Lubicz S, Shafir M, Diamond S, et al. Mallory-Weiss syndrome secondary to cis-platinum chemotherapy: an unusual complication. J Surg Oncol. 1982 Aug;20(4):247-9. http://www.ncbi.nlm.nih.gov/pubmed/7202084?tool=bestpractice.com [22]Fishman ML, Thirlwell MP, Daly DS. Mallory-Weiss tear: a complication of cancer chemotherapy. Cancer. 1983 Dec 1;52(11):2031-2. http://www.ncbi.nlm.nih.gov/pubmed/6684987?tool=bestpractice.com

• Toxins

• Polyethylene glycol lavage (bowel preparation for colonoscopy)

• Chemotherapy agents (e.g., cisplatin)

• Postanesthesia or postsurgery.

A chronic cough can be associated with whooping cough, bronchitis, bronchiectasis, emphysema, COPD, or lung cancer.[23]Annunziata GM, Gunasekaran TS, Berman JH, et al. Cough-induced Mallory-Weiss tear in a child. Clin Pediatr (Phila). 1996 Aug;35(8):417-9. http://www.ncbi.nlm.nih.gov/pubmed/8862904?tool=bestpractice.com

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

Number of lesions

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

• Single tear

• Multiple tears

Endoscopic classification[2]Rumiantsev VV. Clinico-endoscopic classification of Mallory-Weiss syndrome [in Russian]. Vestn Khir Im I I Grek. 1979 Feb;122(2):28-31. http://www.ncbi.nlm.nih.gov/pubmed/312556?tool=bestpractice.com

Proposed endoscopic classification according to endoscopic features of the tear.

• Clean base

• Nonbleeding adherent clot

• Nonbleeding visible vessel (before or after clot removal)

• Actively bleeding or spurting

• Esophageal rupture or perforation (Boerhaave syndrome).

The classification allows physicians to provide a prognosis to determine which patients are safe for discharge, and to plan for those who require further treatment.

[Figure caption and citation for the preceding image starts]: Bleeding Mallory Weiss Tear viewed on retroflexionFrom the personal collection of Douglas Adler; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: Mallory Weiss tear after application of through-the-scope clip results in hemostasisFrom the personal collection of Douglas Adler; used with permission [Citation ends].