Mallory-Weiss syndrome

Last updated: March 23, 2022

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Mallory-Weiss syndrome is characterized by acute upper gastrointestinal bleeding caused by mucous membrane lacerations at the gastroesophageal junction; lacerations may also extend above and/or below the junction. These lacerations are often caused by forceful vomiting in patients with gastric mucosal injury, usually related to heavy alcohol use. Patients typically present with a history of epigastric pain and hematemesis. Patients with severe bleeding may be hemodynamically unstable and, therefore, immediate hemodynamic support (e.g., IV fluid resuscitation and/or blood transfusion) may be necessary. EGD is used in both the diagnosis of Mallory-Weiss syndrome and its treatment, as it may involve simultaneous hemostasis. If EGD is unsuccessful, angiography may be considered; surgery is rarely required. Pharmacological treatment (e.g., antiemetic therapy, acid suppression) should be initiated in all patients with Mallory-Weiss syndrome; further treatment is often not required in patients without active bleeding.

MaLLory-Weiss: Longitudinal Lacerations

Epidemiological data refers to the US, unless otherwise specified.

Approach [2][3][4][5][6]

Suspect Mallory-Weiss syndrome in patients with upper GI bleeding and a history of precipitating factors or predisposing conditions; see “Etiology.”

Blood loss may initially be concealed because of the large volume of the GI tract.

Initial studies [4]

EGD [2][3][5][7][8]

EGD is the gold standard test and can rule out other differential diagnoses of upper GI bleeding.

Angiography [3][5][6][9]

  • Indications
    • Signs of active bleeding without successful location of the tear on EGD
    • EGD unavailable
  • Typical findings: contrast extravasation at the site of active bleeding

See “Differential diagnoses of upper GI bleeding” for details.

The differential diagnoses listed here are not exhaustive.

There are no specific guidelines for the management of Mallory-Weiss syndrome; recommendations are based on guidelines for the management of upper GI bleeding. [2][5][6][8]

Approach [2][4][5][6]

The use of large volumes of IV fluid during resuscitation in patients with ongoing bleeding increases the risk of dilutional coagulopathy, which can worsen the hemorrhage. Consider blood products early.

Pharmacological treatment [2][5][6]

The goal is to promote mucosal recovery.

Initiation of pharmacological therapy should not delay endoscopy.

Conservative treatment with PPI therapy alone is usually sufficient for patients without active bleeding.

Endoscopic treatment [2][3][5][6][8]

  • Indication: first-line treatment for actively bleeding Mallory-Weiss tears
  • Techniques [5]

Angiographic treatment [3][4][5][6][9]

  • Indications
    • Second-line treatment for actively bleeding Mallory-Weiss tears if EGD is unsuccessful
    • Alternative to EGD in patients at high risk for endoscopic complications or if EGD is unavailable
  • Techniques

Surgical treatment [4][6]

  • Indication: only considered if EGD and angiographic treatment are unsuccessful and bleeding is ongoing
  • Technique: surgical ligation of bleeding vessels
  1. He L, Li ZB, Zhu HD, Wu XL, Tian DA, Li PY. The prediction value of scoring systems in Mallory-Weiss syndrome patients.. Medicine. 2019; 98 (22): p.e15751. doi: 10.1097/MD.0000000000015751 . | Open in Read by QxMD
  2. Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021; 116 (5): p.899-917. doi: 10.14309/ajg.0000000000001245 . | Open in Read by QxMD
  3. Singh-Bhinder N, Kim DH, Holly BP, et al. ACR Appropriateness Criteria ® Nonvariceal Upper Gastrointestinal Bleeding. Journal of the American College of Radiology. 2017; 14 (5): p.S177-S188. doi: 10.1016/j.jacr.2017.02.038 . | Open in Read by QxMD
  4. Prasad Kerlin M, Tokar JL. Acute Gastrointestinal Bleeding. Ann Intern Med. 2013; 159 (3): p.ITC2. doi: 10.7326/0003-4819-159-3-201308060-01002 . | Open in Read by QxMD
  5. Karstensen JG, Ebigbo A, Aabakken L, et al. Nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline. Endosc Int Open. 2018; 06 (10): p.E1256-E1263. doi: 10.1055/a-0677-2084 . | Open in Read by QxMD
  6. Barkun AN, Almadi M, Kuipers EJ, et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med. 2019; 171 (11): p.805. doi: 10.7326/m19-1795 . | Open in Read by QxMD
  7. Kim H-S. Endoscopic Management of Mallory-Weiss Tearing. Clin Endosc. 2015; 48 (2): p.102. doi: 10.5946/ce.2015.48.2.102 . | Open in Read by QxMD
  8. ASGE Standards of Practice Committee., Early DS, Ben-Menachem T, et al. Appropriate use of GI endoscopy. Gastrointest Endosc. 2012; 75 (6): p.1127-31. doi: 10.1016/j.gie.2012.01.011 . | Open in Read by QxMD
  9. Loffroy R, Favelier S, Pottecher P, et al. Transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding: Indications, techniques and outcomes. Diagn Interv Imaging. 2015; 96 (7-8): p.731-744. doi: 10.1016/j.diii.2015.05.002 . | Open in Read by QxMD
  10. Songür Y, Balkarli A, Acartürk G, Şenol A. Comparison of infusion or low-dose proton pump inhibitor treatments in upper gastrointestinal system bleeding. Eur J Intern Med. 2011; 22 (2): p.200-204. doi: 10.1016/j.ejim.2010.11.007 . | Open in Read by QxMD

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