Mallory-Weiss tear

Pathophysiology: Mallory-Weiss tears result from a sudden increase in intra-abdominal/intragastric pressure combined with negative intrathoracic pressure during forceful vomiting, retching, or straining (e.g., coughing, hiccupping), causing a longitudinal mucosal and submucosal tear at the gastroesophageal junction—most often on the lesser curvature side. Unlike Boerhaave syndrome, which involves full-thickness esophageal rupture, Mallory-Weiss tears are partial-thickness and typically self-limited.

Clinical associations: Classically seen in alcoholics after binge drinking and subsequent vomiting, but also occurs in patients with bulimia nervosa, hyperemesis gravidarum, or any condition causing severe retching.

Presentation: Patients present with hematemesis (bright red blood or coffee-ground emesis) that occurs after an initial episode of non-bloody vomiting/retching. Pain is usually minimal or absent (distinguishing it from Boerhaave syndrome, which causes severe chest pain).

Diagnosis: Upper endoscopy (EGD) is the diagnostic modality of choice, revealing a linear mucosal tear near the GE junction.

Management: Most cases resolve spontaneously within 24-48 hours with supportive care (IV fluids, antiemetics, PPI therapy). Endoscopic hemostasis (electrocoagulation, clipping, or injection therapy) may be required for active bleeding. Rarely, angiographic embolization or surgery is needed for refractory bleeding.

Prognosis: Generally excellent; most tears heal without intervention. Recurrent bleeding is uncommon.

Key distinction for boards: Mallory-Weiss (mucosal tear, hematemesis after vomiting, usually self-limited) vs. Boerhaave syndrome (full-thickness esophageal rupture, severe chest/back pain, subcutaneous emphysema, mediastinitis, surgical emergency).