Mallory-Weiss tear: symptoms, causes, treatment and recovery

A Mallory-Weiss tear is a tear in the lining of the lower oesophagus, where the food pipe meets the stomach. Patient.info explains that sudden raised pressure within the stomach, or prolapse of the stomach into the oesophagus, produces increased pressure within the non-distensible lower oesophagus and causes tearing. It is also called Mallory-Weiss syndrome when it presents with bleeding.

Tears are an uncommon but important cause of vomiting blood. Patient.info says Mallory-Weiss tears account for 4 to 8% of cases of acute upper gastrointestinal bleeding, and that they are most common between ages 30 and 50 but can occur in children.

Patient.info lists excessive alcohol intake and conditions predisposing to retching and vomiting, including gastroenteritis, hyperemesis gravidarum (the most common cause in women of child-bearing age), bulimia, renal disease, biliary disease, hepatitis, migraine, cyclical vomiting syndrome, gastrointestinal obstruction and chemotherapy. Prolonged coughing, for example from COPD, bronchitis or whooping cough, a hiatus hernia, blunt abdominal trauma, cardiopulmonary resuscitation, and aspirin or other NSAIDs are also listed. In some patients no apparent precipitating factor can be identified.

The NHS notes that damage to the food pipe from being sick or coughing a lot is one of the common causes of vomiting blood, alongside gastritis, stomach ulcers, acid reflux and alcohol-related liver disease. Other causes need to be excluded, which is why tests are needed.

Patient.info says the classic presentation is vomiting blood after a bout of retching or vomiting, although a tear may occur after a single vomit. The NHS describes vomit as ranging from bright red to brown or black, liquid or more solid, or looking like coffee granules.

• Vomiting blood, often after a bout of retching or vomiting.

• Black, tarry stools (melaena).

• Light-headedness, dizziness or fainting.

• Features of whatever caused the vomiting, such as abdominal pain.

The NHS says you should always get medical help if you are vomiting blood. It says to call 999 or go to A&E if you or your child are vomiting blood, or have vomited blood, and feel generally unwell, confused, faint or dizzy, have rapid or shallow breathing, have cold, clammy, pale skin, have tummy pain, or have black poo. It adds that if you have stopped vomiting blood and had no other symptoms, ask for an urgent GP appointment, call 111 or get help from 111 online. Do not drive yourself to A&E.

Patient.info says endoscopy is the primary diagnostic investigation. Other tests include a full blood count to assess the severity of bleeding, clotting studies and platelet counts, kidney function and electrolytes, and blood grouping and cross-matching in case a transfusion is needed. An ECG and cardiac enzymes may be done if myocardial ischaemia is suspected, and angiography may be used for actively bleeding tears if endoscopy fails to find the site.

Doctors also need to exclude other causes of bleeding. Patient.info particularly lists Boerhaave's syndrome, a rupture of the oesophagus, as an important differential after retching with sudden bleeding.

Patient.info says resuscitation is the priority in a significant bleed: maintaining the airway, giving oxygen, correcting fluid losses with large cannulae, and giving blood if a large amount of circulating volume is lost. Once stable, the history and examination are taken, and the severity of blood loss is assessed.

It says Mallory-Weiss syndrome usually follows a benign course but occasionally endoscopic treatment is required to stop bleeding. Endoscopy ideally takes place within 24 hours because tears heal rapidly and may not be apparent at endoscopy after 2 to 3 days. Patient.info says proton pump inhibitor use is not recommended prior to diagnosis by endoscopy. People who are unstable have endoscopy immediately after resuscitation.

A Mallory-Weiss tear is only one cause of vomiting blood, and doctors need to exclude others, which is why tests are needed. The NHS lists the common and less common causes below, and says you should not self-diagnose.

Patient.info lists excessive alcohol intake, repeated vomiting and aspirin or NSAID use among risk factors, so a GP can help review persistent vomiting or coughing, alcohol intake and any aspirin or anti-inflammatory use. The NHS says some medicines, including aspirin, anti-inflammatory painkillers such as ibuprofen and anticoagulant medicines, are less common causes of vomiting blood in general.

Vomiting blood is assessed through emergency departments or acute medical units, with endoscopy performed on the NHS pathway during admission. There is no role for waiting for a routine private appointment when blood is being vomited. After discharge, a GP can follow up on alcohol use, medicines and any underlying conditions such as reflux.