Mallory-Weiss Tear | Johns Hopkins Medicine

What is a Mallory-Weiss tear?

Your esophagus is the tube that carries food from your throat to your stomach. It plays a vital role in digestion. Sometimes, violent coughing or vomiting can tear the tissue of your lower esophagus and it can start to bleed. The condition is called a Mallory-Weiss tear.

What causes a Mallory-Weiss tear?

A Mallory-Weiss tear is most often caused from violent coughing or vomiting. Less common causes are a hiatal hernia, or childbirth, which can increase pressure in your abdomen.

What are the symptoms of a Mallory-Weiss tear?

It can be hard to tell that you have a Mallory-Weiss tear and that you are bleeding inside. But, you may have some of these signs and symptoms:

• Vomit that is bright red or that looks like coffee grounds
• Black or tar-like stools
• Stools with blood present
• Weakness, dizziness, faintness
• Shortness of breath
• Diarrhea
• Paleness
• Abdominal or chest pain

How is a Mallory-Weiss tear diagnosed?

If you have symptoms of a Mallory-Weiss tear, your healthcare provider may check your stool for blood. Your doctor may also do an endoscopy. For this test, your doctor inserts a flexible tube through your mouth, down into your esophagus. A camera at the end of the tube lets the doctor to see the tear inside of your esophagus.

How is a Mallory-Weiss tear treated?

A Mallory-Weiss tear will stop bleeding and begin to heal on its own in most cases. Sometimes you will need treatment. An endoscope may be used to give you an injection or a heat treatment to stop the bleeding, or insert a clip that closes the tear and stops the bleeding.

What are the complications of a Mallory-Weiss tear?

In rare instances, a Mallory-Weiss tear leads to severe internal bleeding. You get a rapid pulse, a drop in blood pressure, problem producing urine, and shock. If bleeding goes untreated, it may result in anemia with fatigue, and shortness of breath.

Can a Mallory-Weiss tear be prevented?

There isn’t a lot you can do to prevent a Mallory-Weiss tear. Avoiding situations that cause violent vomiting (such as the stomach flu) or coughing (such as smoking), can help lessen your risk.

When should I call my healthcare provider?

Blood in your vomit or stool is a serious symptom that calls for urgent medical attention. If you notice any of the symptoms of a Mallory-Weiss tear, contact your healthcare provider right away.

Key points

• A Mallory-Weiss tear is a tear of the tissue of your lower esophagus.
• It is most often caused by violent coughing or vomiting.
• A Mallory-Weiss tear can be diagnosed and treated during an endoscopic procedure.
• If the tear is not treated, it can lead to anemia, fatigue, shortness of breath, and even shock.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your provider tells you.
• At the visit, write down the names of new medicines, treatments, or tests, and any new instructions your provider gives you.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your provider if you have questions.

Mallory-Weiss tear Information | Mount Sinai

Mucosal lacerations – gastroesophageal junction

A Mallory-Weiss tear occurs in the mucous membrane of the lower part of the esophagus or upper part of the stomach, near where they join. The tear may bleed.

The esophagus, stomach, large and small intestine, aided by the liver, gallbladder and pancreas convert the nutritive components of food into energy and break down the non-nutritive components into waste to be excreted.

A Mallory-Weiss tear results from prolonged and forceful vomiting, coughing or convulsions. Typically the mucous membrane at the junction of the esophagus and the stomach develops lacerations which bleed, evident by bright red blood in vomitus, or bloody stools. It may occur as a result of excessive alcohol ingestion. This is an acute condition which usually resolves within 10 days without special treatment.

The stomach connects the esophagus to the small intestines and is where the majority of food digestion takes place.

Causes

Mallory-Weiss tears are most often caused by forceful or long-term vomiting or coughing. They may also be caused by epileptic convulsions.

Any condition that leads to violent and lengthy bouts of coughing or vomiting can cause these tears.

Symptoms

Symptoms may include:

• Bloody stools
• Vomiting blood (bright red)

Exams and Tests

Tests may include:

• CBC, possibly showing low hematocrit
• Esophagogastroduodenoscopy (EGD), more likely to be done when there is active bleeding

Treatment

The tear usually heals in a few days without treatment. The tear may also be fixed by clips that are put in during an EGD. Surgery is rarely needed. Drugs that suppress stomach acid (proton pump inhibitors or H₂ blockers) may be given, but it is not clear if they are helpful.

If blood loss has been large, blood transfusions may be needed. In most cases, bleeding stops without treatment within a few hours.

Outlook (Prognosis)

Repeated bleeding is uncommon and the outcome is most often good. Cirrhosis of the liver and problems with blood clotting make future bleeding episodes more likely to occur.

Possible Complications

Hemorrhage (loss of blood)

When to Contact a Medical Professional

Contact your health care provider if you begin vomiting blood or if you pass bloody stools.

Prevention

Treatments to relieve vomiting and coughing may reduce risk. Avoid excessive alcohol use.

Falk GW, Katzka DA. Diseases of the esophagus. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 129.

Katzka DA. Esophageal disorders caused by medications, trauma, and infection. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 45.

Last reviewed on: 11/3/2022

Reviewed by: Michael M. Phillips, MD, Emeritus Professor of Medicine, The George Washington University School of Medicine, Washington, DC. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Rupture of the esophagus symptoms and causes. Rupture of the esophagus treated in the Ilyinsky hospital.

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• general surgery
• Surgical treatment of diseases of the esophagus
• Rupture of the esophagus

The main cause of esophageal rupture is uncontrollable vomiting caused by alcohol intake or other intoxication. Another reason for the rupture is a complication after operations on the esophagus – anastomosis failure.

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The main threat – death from blood loss, hit
blood into the respiratory tract or mediastinitis (inflammation of the mediastinum).

Main cause of rupture of the esophagus a – indomitable
vomiting caused by alcohol or other intoxication. Another reason
rupture – a complication after operations on the esophagus – anastomosis failure.

Main symptoms – vomiting of blood or blood clots,
severe chest pain, swallowing disorder. Due to blood loss
weakness, dizziness, tachycardia, drop in blood pressure, cold
clammy sweat, confusion or loss of consciousness. When these symptoms appear
you should immediately call an ambulance or go to the emergency department
hospitals.

• Emergency assistance in Ilinskaya
  hospital

Ilinskaya
the hospital is ready around the clock to provide emergency care to patients with a rupture
esophagus. The patient is immediately admitted to the intensive care unit for
to prevent blood from entering the respiratory tract, he is intubated
trachea, the volume of lost blood is compensated, endoscopic
diagnostics, bleeding control and minimally invasive surgery.

• Endoscopy assisted
  installation of a vacuum aspiration system

Patients with
failure of the anastomosis or rupture of all layers of the esophageal wall (syndrome
Boerhaave) surgeons of the Ilyinsky hospital perform minimally invasive endoscopic
manipulation – installation of a vacuum-aspiration system. This is the latest technique
does not require external incisions. With the help of an endoscope, the surgeon brings to the site
rupture of the esophagus, a nasogastric tube, at the end of which a special
a sponge designed to close non-healing wounds for a long time. sponge probe
is fixed at the rupture site and connected to permanent vacuum aspiration.
At the installation site, an area of ​​\u200b\u200blow pressure arises, the sponge is pressed against
rupture site, bleeding stops. Through a sponge gastric tube
draws blood, saliva, food fragments, etc. from the mediastinum. Due to the negative
pressure improves blood circulation, accelerates the healing process. fabrics
the mediastinum is pressed against the rupture site from the outside, which promotes regeneration.
The sponge is replaced every two to three days. In Russia, the installation of a vacuum aspiration
system with incompetent anastomoses and internal bleeding is performed
in just a few clinics, and one of them is the Ilyinsky hospital.

• Endoscopic surgery for incomplete
  rupture of the esophagus

As a result
indomitable vomiting occurs superficial rupture of the abdominal mucosa
esophagus or cardia of the stomach (Mallory-Weiss syndrome – gastroesophageal
ruptured hemorrhagic syndrome). This state is accompanied
bleeding and poses a serious threat to life. Surgeons at Ilinskaya
Hospitals provide patients with superficial esophageal tears with emergency
endoscopic surgery. A thin endoscope is inserted through the mouth into the lumen of the esophagus.
and goes to the damaged area. The gap is closed and fixed with
special clips. The bleeding stops.

• Postoperative care

After
endoscopic hemorrhage control and installation of a vacuum aspiration
system, the patient is placed in the intensive care unit of the Ilyinsky hospital, and
after stabilization of vital signs, he is transferred to the hospital. To treatment
a multidisciplinary team of specialists is involved – surgeons,
gastroenterology, cardiologists, etc. After discharge from the hospital every three
month, the patient undergoes a control endoscopic examination of the esophagus.

ElectedMikhailIgorevich

Surgeon

Candidate of Medical Sciences.

KolyginAlekseyVadimovich

Surgeon

Candidate of Medical Sciences.

Yaskov Konstantin Nikolaevich

Surgeon, specialist in the treatment of wounds and wound infections

Esakov Yury Sergeevich

Thoracic surgeon, oncologist

Candidate of Medical Sciences.

PetrovDemyanIgorevich

Surgeon, oncologist

Candidate of Medical Sciences.

Gavrilov Yan Yanovich

Surgeon, ultrasound specialist

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All your complaints will be considered, and wishes, advice and recommendations will be taken into account. If your request is related
with the work of any doctor or administrative employee of the Ilyinsky hospital, I ask you to indicate his name, as well as in detail
state the complaint, claim and circumstances of the case.

Regards,
Alexei Zhivov, chief physician of the Ilyinsky hospital.

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Dear Patient!

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All your complaints will be considered, and wishes, advice and recommendations will be taken into account. If your request is related
with the work of any doctor or administrative employee of the Ilyinsky hospital, I ask you to indicate his name, as well as in detail
state the complaint, claim and circumstances of the case.

Regards,
General Director of the Ilyinsky Hospital Artyom Gapeev.

Spontaneous rupture of the esophagus

The first reliable description of spontaneous rupture of the esophagus (SOE) is associated with the name of the Dutch surgeon Hermann Boerhaave (1668-1738), who in 1724 described in detail the rupture of the esophagus during vomiting after ingestion of copious amounts of food and liquid, which in turn was the impetus for its subsequent in-depth and detailed study. Boerhaave’s syndrome should be understood as a spontaneous (spontaneous) rupture of the esophagus. There are many synonyms for this disease in the literature: spontaneous rupture, non-traumatic rupture, postemetic rupture of the esophagus, “banquet” syndrome, etc. [4, 12, 33, 35].

H. Boerhaave described an extremely rare variant of esophageal rupture, namely transverse, while in most cases there is a longitudinal rupture of the esophagus, first described by A. Dryden in 1788, and K. Myers (1858) belongs to the priority of its intravital diagnosis, while the first case of recovery of a patient with Boerhaave’s syndrome due to drainage of the pleural cavity was described by N. Frink in 1947 [4, 23].

SRP most often affects the adult population, mostly men (85-90%) at the age of 50-60 years, since the resistance of the walls of the esophagus weakens with age (in childhood, the esophagus withstands pressure 4 times more than in adults), while the literature describes cases of PSA in younger patients [ 19, 20, 24].

An increase in intraesophageal pressure that occurs during vomiting is considered as one of the main factors in the development of Boerhaave’s syndrome, while aggravating factors, according to the unanimous opinion of most researchers, are overeating and alcoholism [21, 29, 30, 35].

During vomiting, there is a sharp tension in the muscles of the anterior abdominal wall, contraction of the diaphragm, muscle membrane of the stomach with simultaneous opening of the esophagocardial sphincter, but with a closed pharyngeal-esophageal sphincter, which leads to a sharp increase in pressure in the lumen of the esophagus (according to the literature, pressure at the border of the esophagocardial sphincter can reach 200 mm Hg). A similar mechanism of SRP is confirmed by the experimental data of R.A. Sulimanova et al. (2004) and M. Maklul (2006).

SRPs are distinguished by the occurrence of large wall defects (from 4–5 to 10–12 cm) and are most often localized on the left wall of the lower thoracic esophagus [20].

In most cases (up to 95%), esophageal ruptures are oriented longitudinally and are localized in the weakest section (3-6 cm above the diaphragm). It should also be noted that in the pathogenesis of spontaneous rupture of the esophagus, a certain role is also played by the peculiarity of the structure of the muscle fibers of the left wall of the lower-middle esophagus, which determines the least resistance to rupture in this zone. In this zone, the muscle fibers of the circular layer are defective due to the entry of nerve trunks and blood vessels [20, 24, 32, 34]. Morphological changes in the wall of the esophagus preceding PSA are described in detail in the work of A.A. Sapozhnikova, M.M. Abakumov and A.N. Pogodina (1975) and are characterized by restructuring of the mucous membrane in the form of leukoplakia and hyperplasia of the mucous glands, hypertrophy of the muscle fibers of the mucous membrane and restructuring with atrophy of part of the fibers of the circular layer, which contribute to the occurrence of a rupture of the wall under conditions of increased intracavitary pressure with a preserved tone of the lower esophageal sphincter.

In Boerhaave’s syndrome, the magnitude of the rupture of the muscular membrane always exceeds the magnitude of the mucosal defect. Often there is a combined injury to the wall of the esophagus and the mediastinal pleura, resulting in communication of the lumen of the latter, as a rule, with the left pleural cavity [18, 27, 35].

There is information about a certain role in the occurrence of PSA hiatal hernia, gastritis, esophagitis, varicose veins of the esophagus, eosinophilic esophagitis (several reports have been published about this rare disease complicated by PSA), which does not manifest itself before rupture [3, 11, 22, 27, 32, 35]. However, the role of the above diseases in the occurrence of PSA is not fully understood.

Currently, Boerhaave’s syndrome is considered as a symptom complex consisting of vomiting, severe pain in the upper abdomen or lower chest, radiating to the interscapular region, difficulty breathing, painful swallowing, shock and intoxication. The latter is due to the ingress of food and the contents of the esophagus into the mediastinum and into the pleural cavity [3, 4, 11, 20, 28]. In the first hours after perforation, as a rule, pain symptoms of indefinite localization prevail, later signs of purulent intoxication, mediastinitis and pleurisy come to the fore. At the same time, pallor and cyanosis of the skin, cold sweat, shortness of breath, tachycardia, chills, hyperthermia can dominate among the general signs [18, 22, 26, 30].

Acute onset of PSA, accompanied by sudden chest pain and shock, may mimic myocardial infarction, as well as perforated gastric and duodenal ulcer, which in turn may be the reason for unsuccessful laparotomy. SRP often has to be differentiated from acute infarction and acute pancreatitis, less often from dissecting aneurysm, diaphragmatic hernia, spontaneous pneumothorax, spontaneous mediastinal emphysema, pharyngeal rupture [4, 7, 14, 28, 31].

Establishing a timely and correct diagnosis in SRP is the most important and at the same time one of the difficult and not fully resolved tasks [3, 7, 16, 24, 29]. Early detection of esophageal injury and subsequent surgical intervention are one of the main success factors in the treatment of this category of patients [7, 16, 31, 34].

Diagnosis of PSA, according to the literature, is based on an assessment of the clinical picture and the use of X-ray examination (plain chest radiography, as well as contrast examination of the esophagus, stomach), X-ray computed tomography (CT) and endoscopic examination (fibroesophagoscopy) [3, 6, 8, 15, 23, 27].

X-ray examination is recommended to begin with plain fluoroscopy and radiography without the use of contrast agents in order to detect gas and fluid in the mediastinum and pleural cavities, as well as soft tissues of the neck. Then, regardless of the results of a non-contrast study, contrasting of the esophagus should be performed, which allows to establish the localization of the rupture and the presence of a cavity in the mediastinum [1, 13, 23].

In contrast X-ray methods of studying the esophagus, the absolute criterion for rupture of its wall is the leakage of the contrast agent beyond the contours of the esophagus, as well as the deposition of the contrast agent in the pleural cavity [2, 16, 17, 25, 33].

As for such objective research methods as ultrasound, CT, their use is limited to a small number of observations [20, 22, 27] and CT semiotics in SRP has not been developed in detail.

Some authors recommend drainage of the corresponding pleural cavity, which makes it possible to suspect and establish damage to the esophageal wall [34].

Fibroesophagoscopy makes it possible to assess not only the extent and nature of the rupture, but also concomitant diseases of the upper digestive tract [28, 31], however, this study can lead to rupture of the mediastinal pleura, tension pneumothorax and acute cardiopulmonary failure. For prophylactic purposes, it is recommended to pre-drain the pleural cavity [16, 21, 26].

Despite the fact that about 90% of patients with SRP seek medical help in the first hours, nevertheless, surgical intervention is often performed late due to late diagnosis [7, 14, 34]. According to some researchers, a delay in the provision of surgical care for more than 24 hours increases mortality by 2 times, and the number of postoperative complications by 2. 5 times [9, 14, 18].

PSA poses a real threat to the patient’s life. Thus, mortality in PSA at the prehospital stage is 75%, postoperative – 25-85% and depends on the time from the moment of rupture of the esophagus to the surgical intervention and the development of complications [13, 21, 31, 34]. Also, one of the main and immediate causes of death in PSA is called multiple organ failure and protein-energy imbalance [25, 28]. According to R. Brauer et al. (1997), on the 1st day without treatment, 65% of patients die, by the end of the 3rd day – already 100%.

When choosing tactics for the treatment of SRP, some authors prefer drainage operations [19, 26], while others believe that the prognosis is significantly improved when the esophageal defect is sutured [4, 16, 28].

Today, a number of authors consider suturing a defect in its wall to be the method of choice for rupture of the esophagus [29, 32, 34], however, this tactic fully justified itself only in the early stages after the rupture [19, 21, 28, 30]. At later stages, the problem of the failure of the suture as a source of preservation, progression of purulent mediastinitis arises [26, 31, 34]. The fundoplication cuff promotes sealing of the sutures of the esophagus, prevents reflux of the contents of the stomach, providing optimal conditions for the healing of the wall defect [3, 5, 23, 28].

In case of extensive ruptures (more than 5 cm), multiple defects of the esophagus, their combination with active esophageal bleeding, and also if necrotic changes in the esophageal wall are detected, resection of the thoracic esophagus is indicated. In the postoperative period, active drainage of the mediastinum and pleural cavities is carried out. In order to unload the esophagus and enteral nutrition, a gastrostomy is formed, through the lumen of which a probe is passed into the small intestine to provide enteral nutrition. Conducting intensive pathogenetic corrective therapy during surgery and in the early postoperative period is an important link in the surgical treatment of patients [3, 16, 32, 35].

Various methods of minimally invasive surgery are used for PSA [23, 26, 31]. S. Landen et al. (2002) in their work, based on the analysis of literature and their own data, indicate that the spectrum of minimally invasive PSA surgery is quite wide and includes thoracoscopy, mediastinoscopy, laparoscopy, endoscopic installation of metal stents and endoscopic clipping. According to the authors, these methods of treatment can be successfully used as an alternative to surgery and due to their use it is possible to avoid severe, thoracic interventions with their complications and high mortality due to sepsis [20, 25, 29].

PSA complications are mediastinitis, pleural empyema, pericarditis, sepsis, abscess pneumonia, arrosive bleeding from mediastinal vessels, esophagomediastinopleural, bronchopleural fistulas [5, 9, 10, 23, 28]. Their early diagnosis is extremely important.

The results of PSA treatment remain disappointing due to the rapid development of purulent mediastinitis with severe septic manifestations [26, 28].