Mallory-Weiss Tear (Esophagus-Stomach Tear)
The human gut allows us to take in food and drink and process it so that we can get the nutrients we need. Waste products in the gut are then evacuated in the form of stool. The entire gut is continuous from the mouth to the rectum. The point where certain parts of the gut meet (junctions) may be prone to tears. One of these high risk areas lie in the upper part of the gut between the esophagus (food pipe) and stomach. If you have been vomiting and suddenly notice bright red blood in the vomit, it is possible that you have one of these tears in the gut known as a Mallory-Weiss tear.
What is a Mallory-Weiss tear?
A Mallory-Weiss tear is a tear in the inner wall of the upper gut around the region where the esophagus and stomach meet. It can occur in the :
- lower part of the esophagus (food pipe) just as it joins with the stomach.
- upper part of the stomach (gastric cardia) just where the esophagus has joined.
- area where the esophagus and stomach join (gastroesophageal junction).
It tends to arise with severe vomiting and retching but usually there is a problem with this area of the gut, like a weakening in the wall seen with a hiatal hernia. There may be a large degree of bleeding from the tear and in severe cases it can lead to significant loss of blood volume. Almost half of all cases follow a bout of excessive alcohol consumption which triggers vomiting and violent retching (dry heaves).
Mallory-Weiss Tear Lesion
A Mallory-Weiss tear is a long tear in the esophagus or stomach. These tears are lines that arise with the shearing forces of vomiting. There are a several possible reasons why a Mallory-Weiss tear may occur particularly during vomiting. Normally during the vomiting process, the gut walls contract in the opposite direction. This pushes food up the gut – from the small intestine, into the stomach, esophagus and up into the throat and mouth. It is a very forceful process and the walls of the gut experience a lot of pressure.
A tear may occur when :
- parts of the gut like the lower esophagus does not stretch enough to be able to withstand the pressure during vomiting.
- a portion of the stomach lying abnormally in the low pressure chest cavity (hiatal hernia) tears more easily with the high pressure of vomiting.
- part of the upper stomach folds into the esophagus with the force of the vomiting.
Mallory-Weiss Tear Causes
Tears arise with any increase in intra-abdominal pressure either arising within the gut or from the outside. Therefore some of the causes of a Mallory-Weiss tear may include :
- Profuse vomiting
- Retching
- Hiccuping
- Persistent coughing
- Excessive screaming
- Blunt force abdominal injury
- CPR (cardiopulmonary resuscitation)
In most cases there is some underlying abnormality or weakening of the gut wall. Some other cause then brings about the vomiting. Sometimes the abnormality of the inner wall of the gut itself can trigger vomiting which then leads to a tear.
Mallory-Weiss Risks
A Mallory-Weiss tear is more likely to happen in a person with one or more of the following risk factors :
- Hiatal hernia
- Excessive alcohol consumption
- Strong emetics (triggers vomiting) used in some traditional systems of medicine
- Gastroenteritis (stomach flu)
- Gastric outlet obstruction (stomach)
- Intestinal obstruction
- Esophagitis
- Hepatitis
- Biliary disease
- Kidney failure
- Cyclical vomiting syndrome
- Eating disorders
- Blood clotting disorder
- Using drugs that may affect blood clotting like aspirin and warfarin.
- Severe morning sickness (hyperemesis gravidarum)
- Raised intracranial pressure.
- Retching during an endoscopy is an uncommon cause (iatrogenic) but possible.
Mallory-Weiss Tear Symptoms
The main symptoms that are characteristic of a Mallory-Weiss tear is bloody vomit (hematemesis) and signs of blood in the stool like melena (dried blood) or hematochezia (fresh blood) which are explained further in detail. Often these are the only signs. Other signs that may also be seen includes :
- Abdominal pain
- Breastbone pain
- Indigestion
- Fainting
- Rapid heart rate (tachycardia)
- Low blood pressure
- Shock with blood loss
Vomiting Blood
Vomiting up of blood, medically known as hematemesis, is the most common symptom of a Mallory-Weiss tear. At first the vomit may appear as normal without any signs of bleeding but is then followed by bloody vomit. This initial vomiting may actually not be due to a Mallory-Weiss tear but may cause the tear. However, sometimes the bloody vomiting due to a tear arises on its own without any vomiting before it. Typically the vomitus is bright red blood because the blood has not as yet been degraded by the stomach acid and enzymes.
Blood in Stool
Blood in the stool may not always be evident. Usually the blood breaks down as it passes from the bleeding tear down the gut to the rectum. If there is a large amount of degraded blood then it causes the stools to appear black and tarry. This is known as melena. When there is heavy bleeding and if the bowel movement is too fast like in diarrhea then the blood from the tear may reach the rectum without breaking down much. The blood in the stool is then red in color and this is known as hematochezia.
Mallory-Weiss Tear Diagnosis
It is important to use diagnostic tools to investigate the gut in upper gastrointestinal bleeding as there are several possible causes apart from a Mallory-Weiss tear.
Differential Diagnosis
These are conditions that may cause symptoms similar to a Mallory-Weiss tear and need to be excluded as a possible cause.
- Esophagitis – inflammation of the esophagus.
- Stomach ulcers (bleeding gastric ulcer) – open sore in the lining of the stomach.
- Boerhaave syndrome – perforation or rupture of the esophagus.
There are various other causes of blood in the vomit that may also need to be considered.
Tests
The main test to identify a Mallory-Weiss tear is an endoscopy. Here a long flexible tube containing a video camera and light at the end is inserted into the mouth and down the throat to view the esophagus and stomach. The Mallory-Weiss lesions are linear tears (long lines) usually about 2 to 3 centimeters in length and just a few millimeters wide. Other tests, like blood tests, may also be done to assess the degree of blood loss and check a person’s health status.
Picture of a Mallory-Weiss tear lesion from Wikimedia Commons
Mallory-Weiss Tear Treatment
A Mallory-Weiss tear often heals on its own within a few days, usually as soon as 2 to 3 days. However, it is important to remove or ease anything that can worsen it. This can be done with medication and a few dietary changes. Significant blood loss will require an IV drip for rehydration and even a blood transfusion in severe cases.
Medication
The medication used is not specifically for a Mallory-Weiss tear.
- Acid-suppressing drugs like proton pump inhibitors (PPIs) and H2-blockers help to reduce the stomach acid.
- Anti-emetic drugs to stop nausea and vomiting.
Any medication that may increase the risk of bleeding or severity of blood loss like blood thinners may need to be stopped immediately but only under the supervision of a doctor if it is a chronic medication.
Diet
A person who has lost a significant amount of blood should fast until advised otherwise by a doctor. This is to allow for an endoscopy to be done and fluids can be resumed thereafter. Usually no specific dietary changes are needed for a person with a Mallory-Weiss tear unless the person has conditions like gastroenteritis and eating trigger vomiting.
Surgery
Surgery is rarely needed for a Mallory-Weiss tear as the area heals on its own within a few days. Electrocoagulation, YAG laser treatment and sclerotherapy can stop bleeding which is continuous or severe. Sometimes clipping or banding techniques may also be used. These procedures can be done endoscopically.
Should these procedures fail and the bleeding is continuing then angiotherapy is considered where the blood supply to the area is reduced. Procedures involving sewing of the tears are only considered when endoscopic procedures and angiotherapy do not yield the desired results.
Mallory-Weiss Tear Outlook
The prognosis for a Mallory-Weiss tear is very good and most cases of bleeding stop on its own without any medical treatment. Recurrence is not common. Only a small number of patients may have significant blood loss requiring transfusions or leading to shock. Here there is some risk of the heart muscle being starved of oxygen (ischemia) and possibly even leading to a heart attack.
Mallory-Weiss Tear Prevention
There is no specific preventative measures in most cases as a tear often arises with no prior warning. Recurrence is uncommon but high risk patients like those with eating disorders and alcoholics need to be informed of the risk of a tear occurring again should they continue to repeat their behavior that leads to vomiting. Patients with a hiatal hernia or other risk factors should be treated for these conditions to prevent future tears.
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