Endoscopy of Mallory-Weiss Tears

Mallory-Weiss syndrome is characterized by longitudinal mucosal lacerations (intramural dissections) in the distal esophagus and proximal stomach, which are usually associated with forceful retching. The lacerations often lead to bleeding from submucosal arteries. Since the initial description in 1929 by Mallory and Weiss in 15 alcoholic subjects, gastroesophageal tears have been a recognized cause of upper gastrointestinal hemorrhage. The prevalence of such tears among patients presenting with upper gastrointestinal bleeding is approximately 5 percent.

How frequently a Mallory-Weiss tear occurs without bleeding cannot be determined with any certainty. It is highly likely that the condition occurs in a less severe form more frequently than is recognized. As an example, the incidence of Mallory-Weiss tears in patients receiving colonoscopic preparation with polyethylene glycol electrolyte lavage solution has been reported at 0.06 percent (2 of 3172 patients). In comparison, we found a higher rate when we studied 1248 consecutive patients receiving a standard preparation of polyethylene glycol electrolyte lavage solution with gastroscopy followed immediately by colonoscopy. A Mallory-Weiss tear was found in 13 patients (1 percent); four developed active bleeding and nine were asymptomatic tears incidentally diagnosed during endoscopy.

PATHOGENESIS

The pathogenesis of this syndrome is not completely understood. Mallory-Weiss tears are usually secondary to a sudden increase in intraabdominal pressure. Precipitating factors include vomiting, straining at stool or lifting, coughing, epileptic convulsions, hiccups under anesthesia, closed-chest massage, blunt abdominal injury, colonoscopic preparation with polyethylene glycol electrolyte lavage solution, and gastroscopy. A case report described fatal bleeding following transesophageal echocardiography and placement of a nasogastric tube during cardiac surgery. The frequency of Mallory-Weiss tears following endoscopic examination appears to be low. In a national survey of the American Society for Gastrointestinal Endoscopy, a tear was found in 0.13 percent of 2320 patients undergoing gastroscopy . Predisposing conditions to Mallory-Weiss tears include hiatal hernia, chronic alcoholism, and perhaps increasing age.

Hiatal hernia — Hiatal hernia has been found in 40 to 100 percent of patients with Mallory-Weiss tears and has been considered by some to be a necessary predisposing factor. It has been proposed that, in hiatus hernia, a higher pressure gradient develops in the hernia compared with that in the rest of the stomach during retching, thereby increasing the potential for mucosal laceration. Gastroesophageal tears may also be more likely to occur when the upper esophageal sphincter does not relax during vomiting. (See "Hiatus hernia".)

Alcoholism — A history of heavy alcohol use leading to vomiting has been noted in 40 to 80 percent of patients with Mallory-Weiss syndrome in most series. The bleeding is usually more severe when Mallory-Weiss tears are associated with portal hypertension and esophageal varices. Occasionally, patients give a history of ingestion of aspirin or nonsteroidal antiinflammatory drug