Mallory Weiss Syndrome

Mallory Weiss syndrome is a longitudinal mucosal laceration at the gastro oesophageal junction, caused by forceful retching or vomiting, presenting with upper gastrointestinal bleeding.

• Accounts for 5 to 15% of upper gastrointestinal bleeds; most affected are men aged 30 to 60 years with alcohol misuse.
• Mechanism: abrupt rise in intragastric pressure against a closed cardia, causing a mucosal and submucosal tear (usually on the gastric side or at the gastro oesophageal junction, lesser curve).
• Risk factors: alcohol, hiatal hernia, vomiting from gastroenteritis, pregnancy (hyperemesis), chemotherapy, bulimia, severe cough, seizures, blunt trauma, cardiopulmonary resuscitation, endoscopy.
• Most bleeding stops spontaneously (80 to 90%), rebleeding is uncommon (under 10%).
• Distinguish from Boerhaave syndrome (full thickness perforation).

• Haematemesis after repeated retching or vomiting (initial non bloody vomitus, then bright red blood).
• Melaena in some; haemodynamic instability if massive bleeding (rare).
• Epigastric or chest pain.
• Signs of alcohol related liver disease or portal hypertension (varices may coexist).
• Boerhaave syndrome suspected if severe chest pain, subcutaneous emphysema, fever, shock.

• Resuscitation first; full blood count, urea, creatinine, coagulation, liver tests, group and save, lactate.
• Upper endoscopy within 24 hours: linear mucosal tear(s) 5 to 20 mm at the gastro oesophageal junction, usually on the lesser curvature, with active bleeding, visible vessel, or clot.
• Risk stratification: Glasgow Blatchford score; Forrest classification.
• CT chest or contrast oesophagram if oesophageal perforation suspected.
• Evaluate for portal hypertension and varices in patients with chronic liver disease.

• Supportive care: IV access, crystalloid, blood transfusion for haemoglobin under 7 g/dL (restrictive strategy; 8 g/dL in cardiovascular disease), correct coagulopathy.
• Most cases resolve spontaneously; treat with antiemetics (ondansetron 4 to 8 mg IV, metoclopramide 10 mg) to prevent further retching.
• Proton pump inhibitor: pantoprazole 40 mg IV twice daily or oral; benefit uncertain but commonly used.
• Endoscopic therapy for active bleeding or visible vessel: epinephrine injection 1:10,000 (4 to 10 mL), haemoclip application (preferred, success over 90%), band ligation, bipolar electrocoagulation, or haemostatic powder; combine injection with mechanical therapy.
• Angiographic embolisation (left gastric artery) or surgery (oversewing of the laceration through gastrotomy) for refractory bleeding.
• Balloon tamponade rarely.
• Alcohol cessation and thiamine for alcohol dependence.
• Discharge with low risk (haemodynamically stable, no ongoing bleeding), review in 1 to 2 weeks.