Mallory-Weiss syndrome (also called Mallory-Weiss tear) is the name given to bleeding and other symptoms caused by a tear in the lining of the upper part of the gut (gastrointestinal tract). It is usually diagnosed by having a test called a gastroscopy (endoscopy). This involves a tube being passed down through the gullet (oesophagus) into the stomach. In many cases, the bleeding has stopped by the time gastroscopy takes place and specific treatment is not needed. The tear usually heals by itself after a few days.
What is Mallory-Weiss syndrome?
Mallory-Weiss syndrome (also called Mallory-Weiss tear) is the name given to bleeding and other symptoms caused by a tear in the lining of the upper part of the gut (gastrointestinal tract). The upper gut consists of the gullet (oesophagus), stomach and duodenum.
The tear usually occurs at one of two particular places in the upper gut:
- The gastro-oesophageal junction - the part of the upper gut where the gullet joins the stomach; or
- Within the lining of the upper part of the stomach.
Mallory-Weiss syndrome was first described in 1929 by two doctors called Mallory and Weiss. They had noticed it in people retching and being sick (vomiting) after bingeing on alcohol.
What causes Mallory-Weiss syndrome and who gets it?
The tear in the lining of the gut that occurs in Mallory-Weiss syndrome can be caused by anything that leads to a sudden rise in pressure in the stomach or the lower part of the gullet (oesophagus). For most people, this is caused by repeated retching and being sick (vomiting) for whatever reason. Less commonly it happens because of violent coughing, hiccupping, excessive straining or heavy lifting. Sometimes an obvious cause for the tear cannot be found.
The problem tends to affect people aged in their 30s to 50s, although it can occur at any age. It is more common in men than in women and is also more common in people with a hiatus hernia. (A hiatus hernia occurs when part of the stomach pushes up into the lower chest through a weakness in the diaphragm - the large flat muscle that lies between the lungs and the tummy area. See separate leaflet called Hiatus Hernia for more details.)
Repeated vomiting and retching after binge drinking, because of severe morning sickness during pregnancy, or because of bulimia nervosa (episodes of binge eating followed by self-induced vomiting) are amongst the most common causes of Mallory-Weiss syndrome. Any condition that causes vomiting or coughing, however, can cause this tear to happen.
What are the symptoms of Mallory-Weiss syndrome?
Most people with Mallory-Weiss syndrome will bring up (vomit) an amount of bright red blood. This will often happen after a bout of normal retching or vomiting. The amount of bleeding (and so blood vomited as a result) varies from person to person. Most people have just a small amount of bleeding but sometimes there can be a lot of blood lost.
Less commonly, stools (faeces) can become dark black or tarry in colour and very smelly. This is caused by blood from the tear in the upper part of the gut passing through to the lower part of the gut and out with the stools. As the blood passes through the gut, it is partly digested so the colour changes from bright red to black. If severe bleeding occurs in the upper part of the gut, bright red blood may be passed via the back passage (rectum). There is not any time for the blood to be digested so the colour does not change.
Some people with Mallory-Weiss syndrome experience pain in the upper part of the tummy (abdomen). They may also feel dizzy and light-headed because of the blood loss. In cases where there is a lot of bleeding, a person can become quite unwell and collapse.
Note: there are many other conditions that can lead to vomiting blood. For example, a stomach ulcer, stomach inflammation (gastritis) or inflammation of the gullet (oesophagus). See separate leaflet called Vomiting Blood (Haematemesis) for more details. Mallory-Weiss syndrome is the cause in around 5 in 100 cases with bleeding from the upper part of the gut. If you experience any of the above symptoms, it is important that you seek medical attention urgently.
How is Mallory-Weiss syndrome diagnosed?
Mallory-Weiss syndrome is usually diagnosed by having a gastroscopy (endoscopy).
A gastroscopy is a test where an operator (a doctor or nurse) looks into the upper part of the gut using an endoscope. Therefore, the test is sometimes called endoscopy. An endoscope is a thin, flexible telescope. It is about as thick as a little finger. The endoscope is passed through the mouth, into the gullet (oesophagus) and down towards the stomach and duodenum. The tip of the endoscope contains a light and a tiny video camera so the operator can see inside the gut. The endoscope also has a side channel down which various instruments can pass. These can be worked by the operator.
A gastroscopy allows the operator to see if a Mallory-Weiss tear is present in the gut lining, as well as its location. They will also be able to see if the tear is still bleeding.
By Samir [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
What is the treatment for Mallory-Weiss syndrome?
The first thing that doctors and nurses will do if they suspect Mallory-Weiss syndrome is to make sure that the person's condition is stable. If a lot of blood has been lost, fluids may be given into the veins (intravenously). Sometimes a transfusion of blood may be given. Blood pressure and pulse rate will be closely watched so that the medical staff can check the response to any treatment.
Blood tests will usually be carried out. For example, to check for anaemia (to see how much blood has been lost because of the bleeding) and to check that the blood is clotting normally. Medication may be given to help with symptoms of feeling sick (nausea) or being sick (vomiting).
Sometimes, people who do not show any signs of ongoing bleeding and whose condition is stable may not be admitted to hospital. Instead they may be followed up as an outpatient.
What happens next will depend on whether the Mallory-Weiss tear is still bleeding when the gastroscopy is carried out. Note: in many cases, the bleeding has stopped by the time gastroscopy takes place.
If the Mallory-Weiss tear is still bleeding
If the tear is still bleeding, treatment to stop the bleeding is usually given during the gastroscopy. A number of different treatments are available. For example:
- The tear can be repaired, or closed, using special metal clips passed via the side channel and so the bleeding is stopped. This is known as haemoclipping.
- A band can be used to tie off a bleeding blood vessel. This is known as band ligation.
- A heater probe may be passed down the side channel of the endoscope to apply a heat source to the bleeding blood vessels, to stop the bleeding.
- Adrenaline (epinephrine) may be injected around the bleeding point. This medication causes closure (constriction) of the bleeding blood vessels. This can stop bleeding in this way. Again, the side channel of the endoscope is used for this.
Sometimes a combination of treatments is used.
Very rarely, the above treatments do not stop the bleeding. In this case a procedure known as angiography with embolisation may be used. A special dye is injected into the bloodstream and X-rays are taken. These X-rays show up the blood vessels (called angiography). In this way, doctors can see where the bleeding is coming from. A substance is then injected into the bleeding blood vessel either to stop the bleeding, or to cause a plug (clot) so that it is closed off (called embolisation).
Rarely, surgery is needed to treat Mallory-Weiss syndrome if other treatments have failed to stop the bleeding. The tear is sewn up (closed up) by the surgeon.
If the Mallory-Weiss tear has stopped bleeding
If the tear is found to have stopped bleeding by the time gastroscopy takes place then no specific treatment may be needed. The tear should heal by itself. The person may be observed in hospital for a period of time so that they can be monitored closely by the doctors and nurses to ensure that bleeding doesn't return (recur). Medication to suppress stomach acid may be given to help the tear heal.
What is the outlook for Mallory-Weiss syndrome?
The outlook (prognosis) is generally very good. In most people, the bleeding stops by itself and no specific treatment is needed. Mallory-Weiss tears usually heal quickly (within a few days).
Can Mallory-Weiss syndrome return?
It is not common for Mallory-Weiss syndrome to return (recur). However, if someone has had Mallory-Weiss syndrome in the past, there is the possibility of the condition recurring. For example, after heavy lifting, violent coughing or being sick (vomiting) frequently for whatever reason. It is more likely to occur again if the bleeding was extremely heavy the first time.
Further reading and references
; Scottish Intercollegiate Guidelines Network - SIGN (September 2008)
; NICE Clinical Guideline (August 2016)
; Diagnosis and management of upper gastrointestinal bleeding. Am Fam Physician. 2012 Mar 185(5):469-76.
; Management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives. World J Gastroenterol. 2012 Mar 2118(11):1202-7.
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