Mallory-Weiss syndrome

A cause of about 10% of upper gastrointestinal bleeding, the Mallory-Weiss syndrome, starts with retching or non-bloody vomiting followed by hematemesis. This pattern has always suggested that the initial emesis itself caused the bleeding. The occasional instance of the syndrome caused by endoscopy⁽¹⁾ confirms that etiology as the endoscopist observes intact mucosa on inserting the instrument, then retching, and subsequently sees the linear tear(s) as he withdraws it. They are believed to be due to ". . . a sudden dramatic increase in intraesophageal pressure."⁽²⁾

Knauer⁽³⁾ observed 58 cases noting that 72% had HH's. There was a noteworthy radial asymmetry in the location of the tears with 52% occurring on the right vs. only 7% anteriorly. the only thing which distinguished Boerhaave's syndrome, from Mallory Weiss is the depth of the laceration. The Mallory-Weiss tear is superficial whereas the Boerhaave tear may rupture the wall. In both, barring Boerhaave's initial case in which the esophagus was completely avulsed from the stomach, the tears are parallel to the long axis of the esophagus.

They could not, as might be expected, be due to overdistention of the esophagus or herniated cardia by sudden ejection of gastric contents as they are seen after retching (i.e., LMC without emesis) and after endoscopy which, of course, is performed on an empty stomach. The wedge shape of the tears⁽⁴⁾ observed after endoscopy induced retching is a further clue that the force is applied at the PEL. If overdistention caused them, they would tend to be eliptical. Like sphincter opening, these syndromes present the paradox of an axial force producing, not the expected transverse tear, but a longitudinal one.

It is, perhaps, puzzling that most of the tears (78%) occur in the stomach just below the mucosal junction. Two circumstances may account for this. 1.) 82% to 100% [Knauer] of the patients have hiatus hernias. The increased friability of the mucosa in the herniated portion of the stomach may account for this localization. 2.) LMC produces a trumpet-like flaring of the GE junction. The further down the trumpet, the more the mucosa is stretched. Thus the wide end of the wedge-shaped tear is aboral. It would be more characteristic of distention to cause a symetrical distribution of tears instead of that actually seen. The angle of insertion of the PEL on the esophagus - which is a factor in the force resolution - is radially asymmetrical so that the stretch is also radially asymetrical.

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References

1. Holmes, G.K.T., Mallory-Weiss syndrome., Lancet 2:161, 1978.

2. Levine, Richard M., In: Gastrointestinal Radiology, Eds, Gore, Richard M., Levine, Mark S. & Laufer, Igor, Eds., W.B. Saunders, Philadelphia, 1994.

3. Knauer, C. Michael, Characterization of 75 Mallory-Weiss lacerations in 528 patients with upper gastrointestinal hemorrhage. Gastroenterology 71:5-8, 1976.

4. 4.Baker, Robert W., Spiro, Alan H. and Trnka, Yvona M., Mallory-Weiss tear complicating upper endoscopy: Case reports and review of the literature. Gastroenterology 82:140-2, 1982.