Mallory-Weiss Syndrome

What is it?

Mallory-Weiss Syndrome is a non-ulcerative lesion of the esophagogastric segment, characterized by acute bleeding caused by a tear in the mucous membrane.

About the condition

It accounts for 10–12% of all gastrointestinal tract bleedings. This condition represents an acute pathology manifested by intense bleeding from longitudinal tears in the lower third of the esophagus and the cardiac section of the stomach. The severity of the hemorrhagic syndrome depends on the depth of the tears in the wall of these organs, which can damage vessels of various diameters in the submucosal plexus, as well as vessels in the muscular and subserosal layers of the esophagus and stomach.
The leading factor in the pathogenesis of this syndrome is the rise in intraesophageal pressure, often in the lower third of the esophagus and esophagogastric junction with a simultaneous rise in intra-abdominal pressure. The main etiological factors include vomiting, retching, and belching. Associated factors may include alcohol intoxication, poisoning, and increased intracranial pressure. Rarely, mucosal tears associated with endoscopic examination may occur.

Symptoms of Mallory-Weiss syndrome include vomiting with blood and clots, resembling “coffee grounds,” and frequent black stools. The only pathognomonic manifestation is profuse upper gastrointestinal bleeding with bright red blood, which occurs following prolonged vomiting.
Modern diagnosis of Mallory-Weiss syndrome is based on comprehensive clinical, radiological, and endoscopic studies. However, among the latter, endoscopic studies are of paramount importance, allowing for the most accurate identification of tears and ruptures.
Treatment of patients with Mallory-Weiss syndrome is comprehensive and includes conservative therapy and endoscopic and surgical manipulations. All therapeutic measures are primarily aimed at stopping bleeding.

Types and classification of Mallory-Weiss Syndrome

The classification of Mallory-Weiss Syndrome distinguishes between 4 degrees of damage:

  • I degree – superficially localized lesions of the mucous membrane of the distal third of the esophagus and cardioesophageal junction;
  • II degree – tears in the same area, but the depth reaches the submucosal layer;
  • III degree – deep tears involving the muscular layer and intense bleeding;
  • IV degree – rupture of all layers of the esophagus, cardioesophageal junction, accompanied by peritonitis, mediastinitis, pneumothorax.

There are also other classification approaches:

  • according to the localization of tears – esophageal, cardioesophageal, cardiac forms;
  • by the number of tears – solitary, multiple;
  • by the depth of tears – superficial, deep, complete tears;
  • by the degree of acute blood loss – mild, moderate, severe;
  • by clinical forms – simple, delirious, with signs of acute liver failure, without signs of liver failure.

Symptoms of Mallory-Weiss Syndrome

What is Mallory-Weiss syndrome in adults clinically? The first manifestation of the pathology is vomiting, containing food particles. After that, vomitus becomes colored red or dark. Vomiting can be forceful. In some patients, Mallory-Weiss syndrome may present with nonspecific symptoms – general weakness and loss of consciousness without vomiting. Sometimes the syndrome manifests with acute abdominal pain, pallor of the skin, and increased pulse. The severity of the symptoms depends on the size and depth of the injury.

Causes of Mallory-Weiss Syndrome

The causes of Mallory-Weiss Syndrome are, on one hand, associated with an increase in pressure within the abdominal cavity, and on the other hand, with an increase in pressure within the stomach. Therefore, risk factors may include the following conditions:

  • vomiting, caused by various factors;
  • traumatic abdominal injuries;
  • forceful coughing;
  • epileptic seizure;
  • asthma attack;
  • severe constipation;
  • childbirth;
  • lifting heavy objects;
  • diving to great depths;
  • fibrogastroscopy.

Another risk factor may be the presence of a hiatal hernia. In the hernial sac, pressure is created similar to that in the stomach. It negatively affects the cardiac zone of the stomach, so tears of varying severity occur during vomiting. Sometimes they can involve almost the entire thickness of the wall, leading to severe bleeding.
Risk of Mallory-Weiss Syndrome may be increased by conditions such as chronic inflammation of the gastric mucosa, peptic ulcer disease of the stomach and duodenum, acute inflammation of the esophagus and pancreas, as well as pseudodiverticulosis in the thoracic part of the esophagus.

Diagnosis of Mallory-Weiss Syndrome

The main method confirming the diagnosis is esophagogastroduodenoscopy (EGD), and in some cases, abdominal X-ray is performed. Laboratory diagnostics play a supportive role.
Esophagogastroduodenoscopy (EGD) is considered the “gold standard” for investigating esophageal and gastric pathologies alongside radiological methods. Visualization of pathological changes in the mucosa, determination of the source of bleeding and its consequences generally provide a complete picture of the pathological process and allow for differential diagnosis.
Tears and fissures are usually localized in the cardiac region from the lesser curvature (inner edge), then extend to the esophagus. Their length can reach 5 cm, and width up to 0.5 cm. Often, 1 defect is detected, but there can be several. Blood clots are found at the base of the fissure, and the edges are soaked in blood. EGD may also detect cardiac insufficiency and esophageal hernia protruding through the diaphragmatic opening.

Treatment of Mallory-Weiss Syndrome

According to clinical guidelines, modern treatment tactics for this syndrome should include methods of endoscopic and conservative hemostasis, and in case of their failure, surgical interventions.
Conservative treatment
Conservative treatment of patients with Mallory-Weiss Syndrome primarily includes hemostatic and blood replacement therapy. In addition, measures are taken to combat hemodynamic disorders and normalize acid-base balance and fluid-electrolyte balance.
Endoscopic hemostasis methods include:
application techniques – adhesive applications, protection of the damaged surface;
injection techniques – embolization of the bleeding vessel, administration of vasoconstrictor, coagulant, hemostatic, sclerosing solutions;
physical agent effects – electrocoagulation, photocoagulation, heat, cold, radiofrequency coagulation;
mechanical interventions – clipping, endoscopic suturing.

Surgical treatment
Surgery is performed if bleeding cannot be stopped with conservative therapy and endoscopic methods. The surgical procedure involves opening the stomach and suturing the defect through the entire thickness of the organ.

Prevention involves preventing episodes of increased intra-abdominal and intra-gastric pressure, that is, addressing the causes of the syndrome.