Excerpt from Mallory-Weiss Tear

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Background

Mallory-Weiss syndrome is characterized by upper gastrointestinal bleeding secondary to longitudinal mucosal lacerations at the gastroesophageal junction or gastric cardia. The original description by Mallory and Weiss in 1929 involved patients with persistent retching and vomiting following an alcoholic binge. However, Mallory-Weiss syndrome may occur after any event that provokes a sudden rise in intragastric pressure or gastric prolapse into the esophagus.

Pathophysiology

A Mallory-Weiss tear (MWT) likely occurs as a result of a large, rapidly occurring, and transient transmural pressure gradient across the region of the gastroesophageal junction. Acute distension of the nondistensible lower esophagus can also produce a linear tear in this region.

With a rapid rise in intragastric pressure due to precipitating factors, such as retching or vomiting, the transmural pressure gradient increases dramatically across the hiatal hernia, which abuts a low intrathoracic pressure zone. If the shearing forces are high enough, a longitudinal laceration eventually occurs. Within the hernia, the tear is more likely to involve the lesser curvature of the gastric cardia, which is relatively immobile compared to the remainder of the stomach.

Another potential mechanism for MWTs is the violent prolapse or intussusception of the upper stomach into the esophagus, as can be witnessed during forceful retching at endoscopy.

Frequency

United States

MWTs account for 1-15% of cases of upper gastrointestinal bleeding.

International

Prevalence probably is similar to that in the United States.

Mortality/Morbidity

• Bleeding from MWTs stops spontaneously in 80-90% of patients. With conservative therapy, most tears heal uneventfully within 48 hours. Thus, a MWT can easily be missed if endoscopy is delayed.
• The degree of blood loss varies. Earlier studies reported that the proportion of patients requiring blood transfusions was 40-70%. These figures do not seem to be the trend today and are probably significantly lower.
• Hemodynamic instability and shock may occur in up to 10% of patients. In one series, mortality as high as 8.6% was attributed to MWTs. Current clinical experience suggests a significantly lower mortality rate from MWTs.

Race

MWTs have no racial predilection.

Sex

Most studies report a male predominance. Male-to-female ratios reportedly are 2-4:1.

Age

Patients usually present in their 40s or 50s, but the age range is quite wide.

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