Mallory-Weiss Tear

Longitudinal mucosal laceration at the GEJ from forceful vomiting or retching

Symptoms / Associated Sx

  • Hematemesis following forceful retching or vomiting — initial vomitus non-bloody, then bloody (classic)

  • Epigastric or lower chest pain

  • Signs of volume depletion if significant bleed

Denies

  • Preceding dysphagia (rules out esophageal cancer)

  • Sudden tearing chest/back pain (rules out Boerhaave — full-thickness perforation)

  • Fever, odynophagia (rules out infectious/inflammatory esophagitis)

  • Melena without hematemesis (rules out lower source as primary)

Social History (SHx)

Heavy alcohol binge (most common), hyperemesis gravidarum, eating disorders, vigorous coughing, post-endoscopy retching.

Main Etiology

  • Forceful retching → sudden intragastric pressure increase → mucosal tear at GEJ

  • Predisposing: hiatal hernia, portal hypertension

Most Common DDx

  • Boerhaave syndrome (full-thickness esophageal rupture — sudden tearing chest/back pain, mediastinal air on imaging, subcutaneous emphysema; surgical emergency vs. self-limited Mallory-Weiss)

  • Variceal bleed (large-volume hematemesis; stigmata of liver disease; cirrhosis history; EGD shows varices not a mucosal tear)

  • PUD (no precipitating retching; epigastric pain precedes hematemesis; EGD shows ulcer)

  • Erosive gastritis (diffuse mucosal injury; no discrete tear at GEJ on EGD; no retching trigger)

  • Aortoenteric fistula (prior aortic graft history; massive hemorrhage; CT shows graft-bowel communication)

DATA

  • CBC, BMP, type and screen, coagulation panel

  • EGD — diagnostic gold standard; identifies tear; therapeutic (hemoclip, epinephrine injection)

  • CT angiography if too unstable for EGD

Home Meds

  • Anticoagulants (hold; reversal if active significant bleed)

  • Antiplatelets, NSAIDs (hold)

Plan

  • ~90% stop spontaneously — conservative management first

  • IV access; fluid resuscitation if hemodynamically compromised; pRBCs if Hgb <7

  • NPO until EGD; Pantoprazole 40 mg IV/PO BID × 4–8 weeks

  • Antiemetics: Ondansetron 4 mg IV q6h PRN; Promethazine 12.5 mg IV q6h PRN

  • EGD within 24h — hemoclip or epinephrine if active bleed or visible vessel

  • Failed EGD → IR embolization (left gastric artery)

  • Treat precipitant: alcohol counseling, hyperemesis management

  • Trend CBC q6–8h; daily BMP; PT/OT if prolonged admission

  • Discharge: PPI PO daily × 4–8 weeks; alcohol cessation resources; avoid NSAIDs; GI follow-up 2–4 weeks

Red Flags

  • Massive hematemesis + hemodynamic instability → resuscitate, airway assessment, urgent EGD

  • Subcutaneous emphysema + chest pain post-vomiting → Boerhaave → CT chest + surgery emergently

  • Cirrhotic + Mallory-Weiss → higher rebleed risk; consider octreotide empirically until varices excluded

  • Failed endoscopic hemostasis → IR embolization → surgery

Senior IM Resident Pearls

  • Boerhaave vs. Mallory-Weiss: Boerhaave = full-thickness (surgical emergency); Mallory-Weiss = mucosal only (usually self-limited). Key differentiator: tearing chest/back pain + mediastinal air = Boerhaave

  • Most tears are at the GEJ lesser curvature — retroflexion during EGD is key to visualize

  • Common mistake: Skipping EGD in stable Mallory-Weiss — always scope to confirm source; varices or PUD may coexist especially in cirrhotics

ORDERS

Labs

Admission Labs

  • CBC with diff

  • BMP

  • CMP if liver disease suspected

  • PT/INR

  • PTT

  • Type & Screen

  • Type & Cross (2–4 units if significant bleed)

Additional Labs

  • LFTs (cirrhosis/varices evaluation)

  • Lactate (hemodynamic instability/shock)

  • Ethanol level if alcohol-related presentation

  • VBG/ABG if unstable

Trending Labs

  • CBC q6–8 hr until stable

  • BMP daily

  • PT/INR daily if elevated or anticoagulated

  • Hgb/Hct after transfusion

Imaging

Usually Not Needed

Diagnosis is made by EGD.

If Unstable

  • CTA Abdomen/Pelvis (active bleeding localization if unable to scope)

Must Not Miss Boerhaave Syndrome

  • CT Chest with IV contrast

  • CXR

Order if:

  • Severe chest pain

  • Back pain

  • Subcutaneous emphysema

  • Crepitus

  • Pneumomediastinum concern

Procedures

Immediately

  • Two large-bore IVs (16–18 gauge)

  • Telemetry

  • Continuous pulse oximetry

  • Strict I&O

Definitive

  • EGD within 24 hr

Therapeutic During EGD

  • Hemoclip placement

  • Epinephrine injection

  • Thermal coagulation if needed

If Failed Endoscopy

  • IR embolization (typically left gastric artery)

Rare

  • Surgical intervention

Medications

Resuscitation

IV Fluids

  • LR 1–2 L IV bolus PRN
    OR

  • NS 1–2 L IV bolus PRN

Blood Products

  • PRBC transfusion if Hgb <7

  • Goal Hgb >8 if CAD/ACS

  • Platelets if <50,000 with active bleed

  • FFP if INR >1.5 with active bleeding

Acid Suppression

Standard

  • Pantoprazole 40 mg IV BID

Significant Bleeding

  • Pantoprazole 80 mg IV bolus

  • Then 8 mg/hr infusion x72 hr

Step-Down

  • Pantoprazole 40 mg PO daily x4–8 weeks

Antiemetics

First-Line

  • Ondansetron 4 mg IV q6h PRN

Alternative

  • Promethazine 12.5 mg IV q6h PRN

Additional Option

  • Metoclopramide 10 mg IV q6h PRN

Cirrhosis / Variceal Uncertainty

Until varices excluded:

  • Octreotide 50 mcg IV bolus

  • Then 50 mcg/hr infusion

Stop if EGD confirms isolated Mallory-Weiss tear.

Hold Medications

  • NSAIDs

  • Aspirin

  • Clopidogrel

  • Ticagrelor

  • Warfarin

  • DOACs

  • Heparin

Consider reversal if significant active bleeding.

Consults

Gastroenterology

  • All admitted patients

  • EGD

Interventional Radiology

  • Failed endoscopic hemostasis

  • Ongoing bleeding

General Surgery

  • Failed IR

  • Massive hemorrhage

  • Suspected Boerhaave syndrome

Thoracic Surgery

  • Confirmed Boerhaave syndrome

Addiction Medicine / Social Work

  • Alcohol use disorder

PT/OT

  • Deconditioning

  • Prolonged admission

Nursing Orders

Monitoring

  • Telemetry

  • Vital signs q4 hr

  • Monitor hematemesis

  • Strict I&O

  • Fall precautions

Diet

  • NPO pending EGD

  • Advance diet after hemostasis

Notify Physician

  • SBP <90

  • HR >110

  • Recurrent hematemesis

  • Syncope

  • Hgb drop >2

Follow-Up Studies

  • Follow CBC trends

  • Follow EGD results

  • Follow pathology if biopsies obtained

  • Follow hemodynamic status

  • Follow alcohol cessation plan

Escalation Criteria

Urgent EGD

  • Active hematemesis

  • Hgb drop >2

  • Ongoing transfusion requirement

ICU

  • Hemorrhagic shock

  • Vasopressor requirement

  • Massive transfusion

  • Airway compromise

Boerhaave Workup

  • Severe chest/back pain

  • Crepitus

  • Pneumomediastinum

→ CT Chest + Thoracic Surgery immediately

IR

  • Failed endoscopic hemostasis

Surgery

  • Failed IR embolization

  • Uncontrolled bleeding