Mallory- Weiss Syndrome 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. 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.
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.
CLINICS: History Presenting symptoms include hematemesis, melena, light-headedness, dizziness, syncope, and abdominal pain.
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Hematemesis: Hematemesis is the presenting symptom in all patients diagnosed with a Mallory-Weiss tear. The diagnosis
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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
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tear. Light-headedness, dizziness, or syncope: Patients with severe vomiting can develop light-headedness or dizziness. These
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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.
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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.
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GI disease o Infectious gastroenteritis o Gastric outlet obstruction o Ulcers o Hiatal hernias o Malrotation o Volvulus
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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. o Gallstones o Cholecystitis Renal disease: Vomiting is often associated with diseases affecting the kidneys, including the following: o Urinary tract infections o Kidney stones o Uteropelvic junction (UPJ) obstruction o Renal failure
PRESENTATION Mallory-Weiss syndrome often presents as an episode of vomiting up blood (hematemesis) after violent retching or vomiting, but may also be noticed as old blood in the stool (melena), and a history of retching may be absent. In most cases, the bleeding stops spontaneously after 24-48 hours, but endoscopic or surgical treatment is sometimes required and rarely the condition is fatal. DIAGNOSIS Definitive diagnosis is by endoscopy. TREATMENT Treatment is usually supportive as persistent bleeding is uncommon. However cauterization or injection of epinephrine to stop the bleeding may be undertaken during the index endoscopy procedure. Very rarely embolization of the arteries supplying the region may be required to stop the bleeding.