Makindo Medical Notes

Related Subjects: |Upper Gastrointestinal Bleed |Oesophageal Variceal Bleeding |Dieulafoy Lesion |Mallory-Weiss Tear |Gastric Cancer |Peptic Ulcer Disease |Oesophagogastroduodenoscopy (OGD/EGD) |Hereditary Haemorrhagic Telangiectasia |Hypovolaemic or Haemorrhagic Shock

📖 About

• First described by Mallory and Weiss in 1929.
• A longitudinal mucosal tear at or just above the gastro-oesophageal junction.
• Important cause of upper GI bleeding – often self-limiting.

🧬 Aetiology

• 💥 Sudden rise in intra-abdominal pressure → mucosal tear.
• ⚠️ Classically follows repeated vomiting or retching, especially on a full stomach.
• 🍷 Often associated with excessive alcohol intake.

👥 Risk Groups

• Alcohol misuse / binge drinking 🍺
• Hyperemesis gravidarum 🤰
• Any disorder with recurrent vomiting (e.g. gastroenteritis, bulimia).

🩺 Clinical Features

• Patients present with haematemesis (usually small volume, fresh blood).
• Bleeding classically follows several retches – not the first vomit.
• Commoner in middle-aged/older adults, more in men.
• Always assess for haemodynamic instability – tachycardia, hypotension, shock. 🚨

🔍 Investigations

• 📊 FBC, U&E, clotting screen – assess anaemia, renal function, bleeding risk.
• 🔦 Upper GI endoscopy – diagnostic and potentially therapeutic.

💊 Management

• Most cases resolve with conservative management (IV fluids, antiemetics, PPI).
• Endoscopic therapy (adrenaline injection, clipping, or thermal coagulation) if active bleeding.
• Very rarely → surgery or interventional radiology for uncontrolled haemorrhage.
• Always address the underlying cause (alcohol misuse, vomiting disorder). ⚕️

📚 References

• Oxford Handbook of Gastroenterology & Hepatology
• BMJ Best Practice – Mallory–Weiss Tear

Cases — Mallory–Weiss Tear & Boerhaave’s Syndrome

• Case 1 — Post-Alcohol Binge 🥂: A 34-year-old man presents with haematemesis after a night of heavy alcohol intake and repeated vomiting. Vitals stable, Hb normal. Endoscopy: linear mucosal tear at the gastro-oesophageal junction, no active bleeding. Diagnosis: Mallory–Weiss tear after forceful retching. Management: Supportive: IV fluids, PPI, observation. Most resolve spontaneously; endoscopic therapy if ongoing bleeding.
• Case 2 — Pregnant Woman with Hyperemesis 🤰: A 28-year-old woman at 12 weeks gestation with severe hyperemesis gravidarum develops sudden small-volume haematemesis after repeated retching. BP 105/70, HR 102. Endoscopy: superficial tear at the GE junction, minor oozing. Diagnosis: Mallory–Weiss tear secondary to hyperemesis. Management: Supportive; antiemetics to control vomiting; PPI safe in pregnancy; monitor haemoglobin. Endoscopic intervention rarely required.
• Case 3 — Boerhaave’s Syndrome (Oesophageal Rupture) 💥: A 46-year-old man with a history of heavy alcohol use develops sudden severe chest pain after repeated vomiting. Exam: tachycardic, febrile, surgical emphysema over the neck. CXR: left-sided pleural effusion, mediastinal air. Diagnosis: Boerhaave’s syndrome (full-thickness oesophageal rupture). Management: Emergency: NBM, broad-spectrum IV antibiotics, IV fluids, surgical (thoracic) referral for repair; high mortality if delayed.

Teaching Contrast 🧠

Mnemonic 📌

Mackler’s Triad for Boerhaave’s Syndrome: - Vomiting 🤮 - Chest pain 💥 - Subcutaneous emphysema (surgical emphysema in neck/chest) 💨 Rarely all present, but highly suggestive when seen together.

Teaching Commentary 🧠

Mallory–Weiss Tear: Mucosal, self-limiting, mainly causes GI bleed. Boerhaave’s Syndrome: Full-thickness rupture, life-threatening, mainly causes mediastinitis/sepsis. 👉 Both follow forceful retching, but Boerhaave’s needs urgent surgical input — a classic “spot the killer diagnosis” exam scenario.