Mallory-Weiss Tear

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately

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Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

The Mallory-Weiss Tear is a medical condition characterised by a tear or rupture that occurs at the junction where the oesophagus meets the stomach. This condition typically manifests as a laceration or shallow ulcer in the lining of the lower part of the oesophagus.
The tear in Mallory-Weiss Tear is often a result of excessive force or pressure placed on the oesophagus. This can happen during episodes of severe vomiting, forceful retching, or even as a consequence of continuous coughing. These actions generate intense strain on the gastroesophageal junction, leading to the formation of a tear.
Patients with Mallory-Weiss Tear usually experience symptoms such as sudden onset of upper gastrointestinal bleeding, often presenting as vomiting blood or the passage of dark, tarry stools. However, it is crucial to note that not all cases of Mallory-Weiss Tear lead to visible bleeding. In some instances, the tear may be too small to cause noticeable bleeding, resulting in more subtle symptoms such as dizziness, light-headedness, and fatigue.

1. Excessive strain during vomiting: The most common cause behind Mallory-Weiss tears is forceful and prolonged episodes of vomiting or retching, often seen in conditions such as alcohol intoxication, eating disorders, or certain gastrointestinal disorders. The repetitive contractions of the abdominal muscles and the force exerted on the gastroesophageal junction can lead to tears in the fragile oesophageal or gastric mucosa.
2. Increased intra-abdominal pressure: Elevations in intra-abdominal pressure can predispose individuals to Mallory-Weiss tears. Conditions such as chronic coughing, heavy lifting, labour during childbirth, or even straining during defecation can raise the pressure within the abdominal cavity. This increased pressure can put strain on the lower oesophagus and stomach, leading to tears in the mucosal lining.
3. Weakened or compromised mucosa: Individuals with pre-existing conditions that weaken or damage the lining of the oesophagus or stomach are more prone to experiencing Mallory-Weiss tears. Examples include chronic gastro-oesophageal reflux disease (GORD) with associated esophagitis, hiatal hernia, or any form of mucosal inflammation such as gastritis or esophagitis caused by infection or medication.
4. Alcohol abuse: Alcohol consumption, particularly excess or chronic intake, is a known risk factor for Mallory-Weiss tears. Alcohol can irritate and inflame the lining of the digestive tract, making it more susceptible to injury during vomiting episodes. Furthermore, alcohol impairs the coordination of the muscles involved in swallowing and vomiting, increasing the chances of forceful retching.

The pathophysiology of Mallory-Weiss Tear involves a combination of mechanical and biochemical factors. The primary contributing factor is the sudden rise in intragastric pressure, which occurs during episodes of forceful vomiting or retching. This increase in pressure puts significant strain on the tissues surrounding the gastroesophageal junction, leading to a tear.
The tear occurs predominantly in the mucosal layer of the oesophagus, involving the longitudinal and sometimes the circular muscle layers as well. The most common site of the tear is near the gastroesophageal junction. However, tears can also occur higher up in the oesophagus in some cases.
Chronic alcohol abuse, oesophageal varices, and gastric or duodenal ulcers can exacerbate the vulnerability of the mucosal layer, making it more prone to tearing during episodes of vomiting. These underlying conditions weaken the structural integrity of the oesophagus, making it more susceptible to damage.
The precise mechanism of the tear formation involves several processes. The rapid and forceful contraction of the diaphragm and abdominal muscles during vomiting causes a sudden increase in intra-abdominal pressure. Simultaneously, the lower oesophageal sphincter, which normally serves as a barrier preventing gastric acid reflux into the oesophagus, momentarily relaxes due to the reflex response to vomiting.
The combination of increased intragastric pressure and transient relaxation of the lower oesophageal sphincter leads to the forceful expulsion of gastric contents into the oesophagus . As a result, the increased pressure within the oesophagus puts strain on the weakened mucosal layer, eventually causing a tear.
The tear itself can vary in severity, ranging from superficial mucosal damage to a full-thickness laceration. The extent of the tear influences the clinical manifestations and potential complications experienced by the individual. Common symptoms associated with Mallory-Weiss Tear include episodes of hematemesis (vomiting of blood), melena (black, tarry stools), and abdominal pain.

• Alcohol consumption: Excessive alcohol intake can lead to recurrent episodes of vomiting, putting considerable stress on the oesophagus and stomach tissues. Alcohol not only relaxes the muscles involved in vomiting but also irritates the lining of the digestive system, rendering it more susceptible to tears. Individuals who engage in heavy drinking or suffer from alcohol use disorder may have an increased risk of Mallory-Weiss Tears.

• Eating disorders: Conditions such as bulimia nervosa, which involve frequent bingeing and purging episodes, can strain the oesophagus and stomach lining. Repetitive self-induced vomiting can cause excessive pressure in the gastrointestinal tract, potentially resulting in a tear.

• Hiatal hernia: A hiatal hernia occurs when a part of the stomach protrudes through the diaphragm into the chest cavity. This condition is associated with an increased risk of gastro-oesophageal reflux disease (GORD). The constant regurgitation of stomach acid into the oesophagus due to GORD can weaken the lining, making it more susceptible to tearing. Consequently, individuals with hiatal hernia are at higher risk of developing Mallory-Weiss Tears.

1. Vomiting blood (hematemesis): One of the most prominent signs of a Mallory-Weiss Tear is the presence of blood in vomit. This blood can range in colour, from bright red to a darker, coffee-ground appearance. The amount of blood can vary depending on the severity of the tear, ranging from small streaks to large amounts.
2. Upper abdominal pain: Individuals with a Mallory-Weiss Tear may experience pain or discomfort in the upper abdomen. This pain is often described as a dull, gnawing ache or a burning sensation. The severity and location of the pain can vary from person to person.
3. Nausea and vomiting: Apart from blood in vomit, individuals may experience recurrent episodes of nausea and vomiting. This vomiting can be associated with retching or dry heaving. The severity and frequency of these episodes can vary, and they are usually triggered by eating or drinking.
4. Weakness and fatigue: Due to the loss of blood associated with a Mallory-Weiss Tear, individuals may feel weak, fatigued, or lightheaded. This is a result of the decreased oxygen-carrying capacity of the blood, and it can be accompanied by pale skin and shortness of breath.
5. Melena: In addition to vomiting blood, some individuals may present with black, tarry stools known as melena. This dark appearance is caused by the digestion of blood as it passes through the gastrointestinal tract.
6. Signs of shock: In severe cases, individuals may exhibit signs of shock such as rapid heartbeat, low blood pressure, and cold, clammy skin. This indicates significant blood loss and requires immediate medical attention.

Endoscopy
The gold standard diagnostic tool for Mallory-Weiss Tear is endoscopy. This procedure involves inserting a flexible tube with a light and camera at the end, known as an endoscope, through the mouth and into the oesophagus, stomach, and duodenum. It allows the direct visualisation and assessment of the location, size, and severity of the tear. It also provides an opportunity for therapeutic interventions such as cauterization or application of clips to stop bleeding.
Imaging Techniques
Barium swallow study
Computed tomography (CT) scans
Laboratory Tests
Full blood count (FBC), renal function, UE and clotting function.

Supportive care: this includes ensuring that the patient is stable, monitoring their vital signs, and providing appropriate pain relief. Intravenous access should be established to administer fluids, especially if there is evidence of hypovolemia or ongoing bleeding.
If the patient is actively bleeding or hemodynamically unstable, immediate resuscitation and referral for endoscopy should be considered. Urgent endoscopy is recommended within 24 hours of the initial presentation for patients suspected of having a Mallory-Weiss Tear with ongoing bleeding or high-risk features such as shock, anaemia, or melena.

If there is no active bleeding during endoscopy and the tear is deemed to be mild, no further specific interventions may be required apart from adequate supportive care. This may include providing proton pump inhibitors (PPI) or histamine H2-receptor antagonists to reduce gastric acid secretion, as well as ensuring appropriate pain relief and monitoring for signs of any complications.

Patients with Mallory-Weiss Tear who do not have ongoing bleeding or high-risk features can be managed conservatively with oral intake restriction for a short period, considered on an individual basis.

Following the initial management, NICE recommends offering appropriate follow-up to patients with Mallory-Weiss Tear. This may include arranging a follow-up endoscopy to assess healing and ensure resolution of symptoms. If symptoms persist or recur, further investigations may be necessary to rule out other causes or complications.

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