Mallory Weiss Tear: Symptoms, Types, Causes and Treatment

Mallory-Weiss tear (MWT) is a relatively common but often misunderstood cause of upper gastrointestinal (GI) bleeding. First described in the 1920s, this condition refers to a tear in the mucosa at the junction of the esophagus and stomach, usually following forceful vomiting or retching. While many cases resolve on their own, others can be alarming, requiring urgent medical intervention. This article takes a comprehensive look at the symptoms, types, causes, and treatment options for Mallory-Weiss tears, drawing on the latest evidence and clinical studies.

Symptoms of Mallory Weiss Tear

The symptoms of a Mallory-Weiss tear can be dramatic and distressing to both patients and caregivers. While hematemesis (vomiting blood) is the hallmark, other signs and symptoms can be present, sometimes making diagnosis challenging.

Symptom	Description	Frequency/Prevalence	Source(s)
Hematemesis	Vomiting of fresh or partially digested blood	Most common presenting symptom	1, 3, 5
Melena	Black, tarry stools due to digested blood	May occur if bleeding is less acute	5
Non-bloody emesis	Vomiting without blood, may precede hematemesis	Often precedes bleeding	1, 5
Syncope	Fainting or lightheadedness from blood loss	Can occur with significant bleeding	1
Epigastric pain	Upper abdominal discomfort or pain	Less common, nonspecific	5

Table 1: Key Symptoms

Hematemesis: The Classic Sign

Hematemsis, or vomiting blood, is the most recognized symptom of Mallory-Weiss tear. In many cases, patients report one or more episodes of non-bloody vomiting, quickly followed by vomiting of bright red or coffee-ground-like blood. However, this “classic” sequence is seen in less than a third of cases; often, blood appears with the first episode of vomiting itself 1, 3, 5.

Other Presenting Symptoms

• Melena: Some patients may notice black, tarry stools, especially if bleeding is less acute or slower, allowing blood to be digested as it moves through the GI tract 5.
• Non-bloody Emesis: A bout of non-bloody vomiting or retching often precedes the bleeding, especially after triggers such as excessive alcohol intake or gastrointestinal illness 1, 5.
• Syncope and Dizziness: Significant blood loss can lead to symptoms of hypovolemia, such as fainting or feeling lightheaded 1.
• Epigastric Pain: Less commonly, patients may report discomfort or pain in the upper abdomen, but this is not specific to Mallory-Weiss tear 5.

Variability in Presentation

It’s important to note that not all patients present with textbook symptoms. Some may have only mild bleeding, while others could have severe hematemesis. In up to a third of cases, another potential source of bleeding is present, complicating diagnosis 1.

Types of Mallory Weiss Tear

Mallory-Weiss tears can differ not just in their location but also in their number and depth. Understanding the variations is key for diagnosis and management.

Type	Description	Prevalence/Location	Source(s)
Single Tear	A solitary mucosal laceration	Most common type	2
Multiple Tears	Two or more mucosal lacerations	27% of cases; requires diligent search	2
Gastric Tear	Lesion confined to gastric mucosa	76% of cases	2
Esophageal Tear	Lesion confined to esophageal mucosa	5% of cases; harder to diagnose	2

Table 2: Types and Locations of Mallory-Weiss Tears

Single vs. Multiple Tears

The majority of Mallory-Weiss tears are single, superficial lacerations. However, in about 27% of cases, two or more tears may be present. Multiple tears can be easily missed if not carefully sought during endoscopy or surgery, potentially leading to ongoing bleeding 2.

Gastric vs. Esophageal Tears

• Gastric Mucosa: Most Mallory-Weiss tears (about 76%) are located entirely within the gastric (stomach) mucosa, just below the gastroesophageal junction 2.
• Esophageal Mucosa: Only 5% are confined solely to the esophagus. These may be harder to detect unless the esophagus is thoroughly examined, sometimes requiring specialized endoscopic techniques 2.

Other Considerations

• Some tears may straddle both the esophageal and gastric mucosa.
• Depth is generally limited to the mucosa; deeper tears (transmural perforation) are rare but more severe and may require surgical intervention 2.

Causes of Mallory Weiss Tear

While forceful vomiting remains the classic cause, Mallory-Weiss tears can result from a surprising range of events and conditions. Understanding the risk factors is crucial for prevention and early recognition.

Cause/Trigger	Description	Relative Frequency	Source(s)
Forceful Vomiting/Retching	Sudden increase in intra-abdominal pressure	~90% of cases	2, 3, 5
Alcohol Abuse	Chronic or binge drinking	~60% of postemetic cases	2, 5
Non-vomiting causes	Coughing, hiccups, straining, lifting	~9-23% of cases	2, 3
Medical Conditions	Bulimia, hyperemesis gravidarum, GERD, scleroderma	Varies by population	5
Iatrogenic/Other	Cardiac massage, anesthesia, primal scream therapy	Rare	2, 4

Table 3: Causes and Triggers of Mallory-Weiss Tears

Forceful Vomiting and Retching

The overwhelming majority of Mallory-Weiss tears arise following intense episodes of vomiting or retching, which sharply increase intra-abdominal pressure and create shearing forces at the gastroesophageal junction 2, 3, 5. This is commonly seen after:

• Excessive alcohol consumption (“alcoholic debauch”) 2, 5
• Acute gastroenteritis
• Severe morning sickness (hyperemesis gravidarum) 5

Non-Vomiting Causes

Interestingly, not all tears are caused by vomiting. About 9–23% of cases are linked to other activities that spike intra-abdominal or thoracic pressure, including:

• Severe coughing fits 2, 3
• Hiccups (prolonged or forceful) 3
• Straining during defecation or heavy lifting 2
• Status asthmaticus, convulsions, or chest compressions 2, 3

Underlying Medical Conditions

Certain medical conditions can predispose individuals to Mallory-Weiss tears:

• Bulimia nervosa: Repeated self-induced vomiting 5
• Hyperemesis gravidarum: Severe vomiting during pregnancy 5
• Scleroderma and GERD: Contribute to mucosal fragility 5
• Chemotherapy-induced vomiting: Increases risk due to both vomiting and mucosal compromise 5

Iatrogenic and Rare Triggers

• Closed chest cardiac massage
• Procedures under anesthesia
• Primal scream therapy (as a case report) 4

Idiopathic Cases

It’s notable that in up to 23% of cases, no identifiable risk factor can be found, underscoring the importance of maintaining clinical suspicion even in atypical scenarios 3.

Treatment of Mallory Weiss Tear

Treatment strategies for Mallory-Weiss tears have evolved significantly in recent decades, driven by advances in endoscopy and interventional radiology. Most cases resolve on their own, but some require active intervention.

Treatment Option	Indication/Description	Efficacy/Notes	Source(s)
Supportive Care	For stable, non-bleeding or minor bleeding cases	Most cases resolve spontaneously	1, 5, 10
Endoscopic Therapy	Active or high-risk bleeding (e.g., epinephrine, band ligation, hemoclipping, MPEC)	High efficacy, several modalities available	6, 7, 10
Angiotherapy/Embolization	Persistent or recurrent bleeding not controlled endoscopically	Effective alternative, especially if surgery contraindicated	1, 8, 9, 10
Surgery	Rare, for uncontrolled bleeding or perforation	Reserved for severe cases	1, 10

Table 4: Treatment Approaches for Mallory-Weiss Tears

Supportive Management

• Observation: Most Mallory-Weiss tears stop bleeding spontaneously and require only supportive care—fluids, monitoring, and possibly blood transfusions if significant blood loss occurs 1, 5, 10.
• Transfusion: About a third of patients may need transfusion depending on blood loss; massive bleeding is uncommon 1.

Endoscopic Therapies

Endoscopic treatment is the mainstay for active or high-risk bleeding:

• Epinephrine Injection: Rapid, first-line therapy but should be used cautiously in those with heart disease due to potential systemic effects 6, 7, 10.
• Band Ligation: Effective and safe for actively bleeding tears 6, 10.
• Hemoclipping: Emerging as a first-line option where available 10.
• Multipolar Electric Coagulation (MPEC): Supported by strong evidence for safety and efficacy, except when esophageal varices are suspected 10.
• Polidocanol Injection: Alternative in selected scenarios 10.
• Combination Therapy: Some studies suggest combining agents (e.g., epinephrine + polidocanol) may further reduce risk of rebleeding 7.

Angiotherapy and Embolization

• Intraarterial Vasopressin Infusion: Useful for persistent bleeding; cardiac complications possible 1, 9.
• Gelfoam Embolization: Effective, particularly when endoscopic methods fail or surgery is too risky 8, 10.
• Indication: Reserved for cases where bleeding continues or recurs despite endoscopic therapy, or if surgery is contraindicated 8, 9, 10.

Surgery

• Indication: Last resort for cases with uncontrolled bleeding or transmural perforation 1, 10.
• Approach: Direct suturing of tears; requires careful exploration as multiple tears may be present 2.

Special Considerations

• Patient Comorbidities: Choice of therapy depends on the patient’s overall health, risk factors, and availability of expertise 10.
• Prognosis: Mortality has decreased with improved recognition and advances in supportive and endoscopic treatments 2.

Conclusion

Mallory-Weiss tear is a significant cause of upper GI bleeding, often presenting with dramatic symptoms but typically having an excellent prognosis with prompt recognition and management. Here’s a summary of the main points:

• Symptoms: Most often presents with hematemesis, but can also involve melena, non-bloody vomiting, and, rarely, syncope or epigastric pain 1, 3, 5.
• Types: Most tears are single and located at the gastric side of the gastroesophageal junction; multiple or esophageal-only tears can occur and may be missed without careful examination 2.
• Causes: Usually follows forceful vomiting or retching, especially after alcohol use, but can also result from coughing, hiccups, or underlying conditions like bulimia and hyperemesis gravidarum. Some cases have no clear cause 2, 3, 5.
• Treatment: Most cases resolve with supportive care; persistent or severe bleeding is managed with endoscopic therapies, angiotherapy, or, rarely, surgery. Advances in endoscopy have markedly improved outcomes 1, 6, 7, 8, 9, 10.

Prompt diagnosis and tailored management are key to ensuring the best outcomes for patients with Mallory-Weiss tears.