AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

In 1929, Kenneth Mallory and Soma Weiss first described a syndrome characterized by esophageal bleeding caused by a mucosal tear in the esophagus as a result of forceful vomiting or retching. The initial description was associated with alcoholic bingeing; however, with the advent of endoscopy, Mallory-Weiss tears have been diagnosed in many patients with no antecedent history of alcohol intake. Although the tear typically occurs after repeated episodes of vomiting or retching, it may occur after a single incident.¹ Although most written reports of these tears relate to adults, Mallory-Weiss tears also occur in children.

Pathophysiology

Any disorder that initiates vomiting may result in the development of a Mallory-Weiss tear, which develops as a linear laceration at the gastroesophageal junction because the esophagus and stomach are cylindrical. The cylindrical shape allows longitudinal tears to occur more easily than circumferential tears. These tears have been postulated to occur either by a rapid increase in intragastric pressure and distention, which increases the forceful fluid ejection through the esophagus, or secondary to a significant change in transgastric pressure (ie, difference in pressure across the gastric wall) because negative intrathoracic pressure and positive intragastric pressure leads to distortion of the gastric cardia, resulting in a gastric or esophageal tear. Because of these factors, Mallory-Weiss tears occur more commonly in people with hiatal hernias.

Frequency

United States

Mallory-Weiss tears cause approximately 10-15% of all episodes of hematemesis in adults; however, these tears occur much less commonly in children (<5% of all upper GI bleeding episodes).

Mortality/Morbidity

The major complication of a Mallory-Weiss tear is bleeding.² Patients present with variable bleeding, which can range from a few specks or streaks of blood mixed with mucus to copious amounts of fresh red blood. In adults, shock occurs in as many as 20% of patients bleeding from Mallory-Weiss tears who present to emergency departments; as many as 45% of patients develop postural hypotension. In contrast, children rarely have hemodynamic instability.

Sex

Mallory-Weiss tears are equally common among male and female children. These tears also occur with equal frequency in both sexes in adults, although they have different causes. In women of childbearing age, the most common cause of these tears is hyperemesis gravidarum, which usually occurs in the first trimester, causing severe persistent nausea and vomiting. Any adolescent female presenting with a Mallory-Weiss tear should be evaluated for pregnancy.

Age

Mallory-Weiss tears usually occur in the fifth and sixth decades of life. In children, tears are more commonly observed in older children and adolescents secondary to increased intragastric and transgastric pressures that develop at an older age.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Presenting symptoms include hematemesis, melena, light-headedness, dizziness, syncope, and abdominal pain.

• Hematemesis: Hematemesis is the presenting symptom in all patients diagnosed with a Mallory-Weiss tear.³ The diagnosis does not depend on the amount of hematemesis because it can vary from blood flecks or streaks of blood mixed with gastric contents or mucus to several ounces of bright red bloody emesis. In most children, hematemesis is preceded by one or more episodes of nonbloody emesis; however, hematemesis secondary to a Mallory-Weiss tear has been reported to occur during the first bout of vomiting.
• Melena: Melena has been reported to occur in as many as 10% of patients who have been diagnosed with a Mallory-Weiss tear.
• Light-headedness, dizziness, or syncope: Patients with severe vomiting can develop light-headedness or dizziness. These symptoms usually occur secondary to dehydration from the underlying cause of vomiting and are not secondary to blood loss from the Mallory-Weiss tear. Only in rare cases does a Mallory-Weiss tear lead to anemia requiring transfusions.
• Abdominal pain, dyspepsia: As many as 40% of patients may experience epigastric pain or symptoms of heartburn. These symptoms are often related to the underlying cause of vomiting and not specifically to the Mallory-Weiss tear.

Physical

• No specific physical findings can be linked to the diagnosis of a Mallory-Weiss tear. Physical findings are linked to the underlying disorder causing the vomiting and retching.

Causes

Many underlying disorders that cause vomiting and retching result in a Mallory-Weiss tear.

• GI disease
• • Infectious gastroenteritis
  • Gastric outlet obstruction
  • Ulcers
  • Hiatal hernias
  • Malrotation
  • Volvulus
  • Inflammatory conditions of the stomach and intestine
• Pregnancy: Some women develop hyperemesis gravidarum, a syndrome characterized by persistent severe vomiting and retching, in the first trimester of pregnancy. Gastric dysrhythmias and prolonged small-bowel motility cause the development of hyperemesis gravidarum. Some women lose as much as 10% of their body weight during this period.
• Hepatitis: Acute inflammation of the liver causes vomiting in 10-20% of patients.
• Biliary tract disease: Although rare in children, these conditions can cause vomiting typically associated with meals.
• • Gallstones
  • Cholecystitis
• Renal disease: Vomiting is often associated with diseases affecting the kidneys, including the following:
• • Urinary tract infections
  • Kidney stones
  • Uteropelvic junction (UPJ) obstruction
  • Renal failure
• Increased intracranial pressure: Intracranial lesions that cause hydrocephalus or increased intracranial pressure may lead to vomiting in children. Most common causes of hydrocephalus include tumors, cysts, and congenital abnormalities. Other causes of increased intracranial pressure consist of trauma, infections (eg, meningitis), medications, and pseudotumor cerebri.
• Iatrogenic causes: Complications of endoscopy may cause esophageal tears (<0.01% in children) and are almost always associated with a patient who is retching or struggling during the procedure. The use of polyethylene glycol lavage, when used for ingestions, severe constipation, or preparation for colonoscopy, may cause severe vomiting.
• Other causes
• • Severe diabetic ketoacidosis
  • Toxins
  • Drugs (eg, chemotherapeutic agents)
• Cyclic vomiting syndrome

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Esophageal varices
Gastric varices
Hemoptysis
Hemangioma
Nasopharyngeal trauma

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• No specific laboratory tests are indicated for determining the etiology of a Mallory-Weiss tear.
• Obtain a CBC count to determine the severity of bleeding.

Imaging Studies

• No specific imaging studies exist that can positively identify an esophageal tear.
• Several retrospective studies have demonstrated that barium esophagraphy may reveal small esophageal hematomas or thick streaks where the barium becomes trapped in the tear. However, only 20% of patients with a Mallory-Weiss tear had positive radiologic findings, and, in all cases, an upper endoscopy was performed for definitive diagnosis.

Procedures

• Esophagogastroduodenoscopy⁴
• • Upper endoscopy is the diagnostic tool for esophageal tears.⁵
  • Visual inspection of the esophagus, stomach, and duodenum is essential in the evaluation of a child presenting with hematemesis.
  • The hallmark of a Mallory-Weiss tear is the visual appearance of one or more linear bleeding lesions at or just proximal to the esophagogastric junction.
  • Perform endoscopy within 24 hours of the bleeding episode.
  • Tears visualized within 24 hours usually have a soft, fresh, mounded, brownish-red appearance on the surface of the mucosa.
  • After 48-72 hours, the tear looks like a mucosal cleft that may be surrounded by erythematous mucosa.
  • By 96 hours, most Mallory-Weiss lesions are well healed and may be difficult to visualize.
  • In cases of severe bleeding with hemodynamic instability, the patient should be stabilized prior to performing endoscopy.
  • Mallory-Weiss tears can heal quickly after the cessation of vomiting and retching and may not be diagnosed if performance of the upper endoscopy is delayed.

Staging

Predictive factors for recurrent bleeding include the following:⁶ 

1. Initial presentation of shock
2. Liver cirrhosis
3. Decreased hemoglobin and platelet count
4. Need for blood transfusion

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Initial medical management is always supportive. Patients in whom conservative medical therapy is ineffective should have a consultation with a gastroenterologist for possible endoscopy.

• Monitor vital signs closely, obtain a CBC count, and place a large-bore intravenous tube for fluid resuscitation.
• Less than 5% of children require a blood transfusion.
• Begin workup to determine the underlying cause of the retching and vomiting.
• In most cases, Mallory-Weiss tears spontaneously resolve; however, consider pharmaceutical therapy in cases of persistent bleeding or complications (see Medication).
• Esophageal balloon tamponade, although useful for patients with esophageal varices, should be considered only in extreme cases because the use of an esophageal balloon increases the risk of extending the esophageal tear.
• Endoscopic band ligation has been used by one center and was shown to be an effective and safe procedure for patients with severe bleeding.⁷
• Angiographic embolization of the vessels supplying blood flow to the esophageal tear has been reported in the adult literature but should be considered in children only under dire circumstances.

Surgical Care

Only in extraordinary cases should surgical intervention be required. A consultation with a surgeon should be considered only in patients with persistent bleeding requiring transfusions and in whom the bleeding cannot be controlled by medication or by therapeutic upper endoscopy (see Medication).

Consultations

An upper endoscopy (performed by a trained pediatric gastroenterologist) should be considered for all patients with persistent bleeding for whom medical therapy is unsuccessful.

Diet

• During the acute problem, keep patients on nothing by mouth (NPO).
• Once resolved, provide the patient clear liquids and advance the diet as tolerated.
• After complete resolution, no special diet is required. However, foods or liquids that may have been identified as contributing to the cause of the underlying problem (eg, excessive alcohol intake, food allergies) should be avoided.

Activity

Once the esophageal bleeding has stopped, no activity restrictions are required.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Vasopressin administered systemically may control cases of severe bleeding.

Drug Category: Vasoconstrictors

These agents are used to decrease blood flow in the distal esophagus.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Two types of endoscopic therapy can be used to control severe bleeding in patients who are hemodynamically unstable because of bleeding from a Mallory-Weiss tear.
• • Injection therapy is favored as the first-line therapy by most endoscopists for control of bleeding esophageal lesions because of its ease of use, safety, and cost. Typically, the injections are made 3-5 mm apart circumferentially around the site of bleeding in 4 areas. The chemical agents used for injection therapy include dilute epinephrine, sodium morrhuate, ethyl alcohol, or sodium tetradecyl sulfate.
  • Heater probe or bipolar coagulation therapies use electrical current supplied by catheters that can be inserted into an endoscope to control bleeding. Approximately 20 joules (10-15 Watts) of current are used per individual pulse, and treatment is complete when the bleeding has ceased. The current is usually delivered in repeated time-limited pulses.
• Evaluate the underlying cause of vomiting.

Further Outpatient Care

• Mallory-Weiss tears almost never rebleed; thus, follow-up is not usually indicated.

Transfer

• Transfer children with severe uncontrolled bleeding to a tertiary care hospital with an in-house pediatric gastroenterologist.

Deterrence/Prevention

• Avoid and treat causes of underlying vomiting and retching.

Complications

• Anemia
• Dehydration

Prognosis

• Prognosis is extremely good in children, with a less than 0.01% mortality rate. These tears almost always respond to conservative therapy and supportive care.⁸

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• The most common medicolegal pitfall is the failure to monitor intravascular volume.
• Significant fluid shift may occur, especially with vasopressin therapy; thus, closely monitor serum sodium and urine output.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. Graham DY, Schwartz JT. The spectrum of the Mallory-Weiss tear. Medicine (Baltimore). Jul 1978;57(4):307-18. [Medline].
2. Harris JM, DiPalma JA. Clinical significance of Mallory-Weiss tears. Am J Gastroenterol. Dec 1993;88(12):2056-8. [Medline].
3. Yu PP, White D, Iannuccilli EA. The Mallory-Weiss syndrome in the pediatric population. Rare condition in children should be considered in the presence of hematemesis. R I Med J. Feb 1982;65(2):73-4. [Medline].
4. Ament ME, Gans L, Christie DK. Experience with esophagogastro-duodenoscopy in diagnosis of 79 pediatric patients with hematemesis, melena or chronic abdominal pain. Gastroenterology. 1975;68:858-61.
5. Countryman D, Norwood S, Andrassy RJ. Mallory-Weiss syndrome in children. South Med J. Nov 1982;75(11):1426-7. [Medline].
6. Kim JW, Kim HS, Byun JW, et al. Predictive factors of recurrent bleeding in Mallory-Weiss syndrome. Korean J Gastroenterol. Dec 2005;46(6):447-54. [Medline].
7. Higuchi N, Akahoshi K, Sumida Y, et al. Endoscopic band ligation therapy for upper gastrointestinal bleeding related to Mallory-Weiss syndrome. Surg Endosc. Sep 2006;20(9):1431-4. [Medline].
8. Kerlin P, Bassett D, Grant AK. The Mallory-Weiss lesion: a five-year experience. Med J Aust. May 6 1978;1(9):471-3. [Medline].
9. Kelly JA. Mallory-Weiss tear. In: Altschuler SM, Liacouras CA, eds. Clinical Pediatric Gastroenterology. Philadelphia, Pa: Chuchill-Livingstone; 1999:303-5.

Article Last Updated: Mar 21, 2008