Mallory–Weiss tear is one of those Step-friendly GI diagnoses that rewards pattern recognition: a sudden episode of hematemesis after forceful vomiting/retching, usually in someone who’s been drinking or has had repeated emesis. It’s common, high-yield, and—unlike varices—often self-limited. Here’s the deep dive you actually need for exams and wards.
What is a Mallory–Weiss tear?
A Mallory–Weiss tear is a longitudinal mucosal laceration at the gastroesophageal junction (distal esophagus/proximal stomach) caused by a sudden increase in intra-abdominal pressure (classic: retching).
Key definition points (Step-ready):
- Depth: Mucosa ± submucosa (not full-thickness)
- Location: GE junction (often along the gastric cardia)
- Bleeding source: Tears can disrupt submucosal vessels → upper GI bleed
Pathophysiology (why it happens)
Mechanism
Forceful vomiting/retching → abrupt pressure changes across the GE junction → mucosa shears → linear lacerations.
Common precipitating settings
- Alcohol use disorder (classic association—also due to gastritis, vomiting)
- Bulimia nervosa (recurrent self-induced vomiting)
- Hyperemesis gravidarum
- Gastroenteritis, cyclic vomiting, severe coughing, seizures (anything that mimics retching)
HY contrast: Mallory–Weiss vs Boerhaave
This is a favorite comparison on Step 1 and Step 2:
| Feature | Mallory–Weiss tear | Boerhaave syndrome |
|---|---|---|
| Depth | Mucosal tear | Transmural rupture |
| Typical symptom | Hematemesis after retching | Severe chest pain after vomiting |
| Complications | Usually self-limited bleeding | Mediastinitis, sepsis |
| Exam clue | Upper GI bleed, stable-ish | Toxic, crepitus (subQ emphysema) |
| Imaging clue | Diagnosed via EGD | Contrast esophagram/CT; pleural effusion |
| Treatment | Supportive/endoscopic hemostasis | Broad-spectrum antibiotics + surgery/repair |
Clinical presentation (what they’ll describe)
Classic vignette
A patient (often after heavy drinking) has several episodes of forceful non-bloody vomiting, then suddenly hematemesis.
Symptoms and signs
- Hematemesis (bright red or coffee-ground)
- Melena can occur (less common than hematemesis)
- Epigastric discomfort; may be asymptomatic aside from bleeding
- Vital signs range from stable to tachycardia/hypotension if brisk bleed
High-yield differentiators in upper GI bleed
- Mallory–Weiss: hematemesis after retching
- Esophageal varices: massive hematemesis in cirrhosis/portal HTN (often no preceding retching)
- Peptic ulcer disease: epigastric pain + melena/hematemesis (NSAIDs, H. pylori)
- Gastritis: alcohol/NSAIDs/stress; diffuse mucosal oozing
Diagnosis (how you confirm it)
Initial approach (Step 2 style)
Treat any suspected upper GI bleed like an emergency until proven otherwise:
- Assess airway and hemodynamics
- IV access (2 large-bore IVs)
- Labs: CBC, CMP, PT/INR, type & screen/cross
- Resuscitate with fluids ± transfusion as needed
Definitive test
- Upper endoscopy (EGD) is diagnostic (and can be therapeutic)
Endoscopic finding: linear mucosal laceration at the GE junction with or without active bleeding.
What you don’t need first (most cases)
- Barium studies are not first-line in acute upper GI bleed.
- CT is not the diagnostic test for Mallory–Weiss (think Boerhaave if severe chest pain, crepitus, fever).
Treatment (what you do on exams and in real life)
Most cases: supportive care
Mallory–Weiss bleeding is often self-limited.
Core management:
- NPO initially
- IV fluids
- PPI therapy (commonly given in upper GI bleed algorithms)
- Antiemetics to prevent recurrent retching
If active bleeding or high-risk features → endoscopic hemostasis
Endoscopic options include:
- Epinephrine injection
- Thermal coagulation
- Hemoclips/banding (depending on lesion and operator preference)
If endoscopy fails (rare)
- Angiographic embolization or surgery (uncommon)
Transfusion (Step-style thresholds)
Use clinical context, but many algorithms target transfusion when:
- Hemoglobin < 7 g/dL in most stable patients
- Higher threshold in ongoing brisk bleeding, CAD, symptoms, etc.
High-yield associations & testable pearls
Risk factors they love to mention
- Alcohol binge → vomiting → hematemesis
- Bulimia → repeated vomiting/retching
- Pregnancy (hyperemesis gravidarum)
Why it bleeds
- Tear can nick submucosal vessels at the GE junction.
Prognosis
- Usually excellent; recurrence is possible if vomiting continues.
Complications (uncommon)
- Persistent hemorrhage requiring endoscopic therapy
- Aspiration risk if severe vomiting/bleeding
First Aid cross-references (where it lives conceptually)
Mallory–Weiss is typically grouped with esophageal tears/ruptures and upper GI bleeding causes in First Aid.
First Aid-style hooks:
- “Severe vomiting → Mallory–Weiss tear (mucosal tear) → hematemesis”
- Contrast with:
- Boerhaave syndrome: severe vomiting → esophageal rupture
- Esophageal varices: portal HTN → dilated submucosal veins (massive bleed)
If you’re building a mental “upper GI bleed map,” Mallory–Weiss sits in the esophagus/GE junction bucket with a mechanical trigger (retching) rather than acid/NSAIDs (PUD) or portal HTN (varices).
Rapid review: Step 1/2 one-liners
- Dx: EGD shows linear mucosal laceration at GE junction after retching.
- Presentation: hematemesis following forceful vomiting (often alcohol use).
- Tx: Usually supportive; endoscopic hemostasis if ongoing bleeding.
- Key distinction: Mallory–Weiss = mucosal tear, Boerhaave = transmural rupture + mediastinitis.
Mini practice vignette (to lock it in)
A 28-year-old man has repeated vomiting after a night of heavy alcohol use. He now has bright red hematemesis and mild epigastric discomfort. Vitals are stable. What is the most likely cause?
Answer: Mallory–Weiss tear—a mucosal laceration at the gastroesophageal junction due to retching.