Mallory-Weiss Syndrome

Mallory-Weiss syndrome is the name given to bleeding and other symptoms caused by a tear in the lining of the upper part of the gastrointestinal tract (gut). It is usually diagnosed by having a gastroscopy (endoscopy). 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 is the name given to bleeding and other symptoms caused by a tear in the lining of the upper part of the gastrointestinal tract (gut). The upper gut consists of the oesophagus (gullet), stomach and duodenum. The tear is known as a Mallory-Weiss tear.

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 oesophagus (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 when they noticed it in patients with severe retching and 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 oesophagus (gullet). For example, in people with repeated retching and vomiting for whatever reason. Less commonly because of excessive straining or lifting, violent coughing or hiccuping. Sometimes an obvious cause for the tear cannot be found.

The problem tends to affect people aged in their 40s and 50s, although it can occur at any age. It is more common in men than women and is also more common in people with a hiatus hernia. (A hiatus hernia is where part of the stomach pushes up into the lower chest through a defect in the diaphragm - the large flat muscle that separates the lungs from the abdomen. 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.

What are the symptoms of Mallory-Weiss syndrome?

Most people with Mallory-Weiss syndrome will 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 bleeding can be quite severe.

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 rectum (back passage). 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 abdomen. They may also feel dizzy and light-headed because of the blood loss. In cases where bleeding is more severe, a person can become quite unwell and collapse.

Note: there are many other things that can cause bleeding from the upper part of the gut. For example, a stomach ulcer, stomach inflammation (gastritis) or inflammation of the oesophagus (gullet). 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 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 manipulated by the operator.

For further details see separate leaflet called 'Gastroscopy'.

A gastroscopy allows the operator to identify 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.

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 intravenously (into the veins). Sometimes a transfusion of blood may be given. Blood pressure and pulse rate will be closely monitored 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 check 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 nausea or vomiting.

Once the person's condition is stable, they will usually be kept in hospital and referred for a gastroscopy (as described above). Sometimes, younger people who do not show any signs of ongoing bleeding and whose condition is stable may not be admitted to hospital and 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:

  • 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 drug causes constriction (closure) of the bleeding blood vessels and so can stop bleeding in this way. Again, the side channel of the endoscope is used for this.
  • 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.

Sometimes a combination of treatments is used.

If the above treatments do not stop the bleeding, then a procedure known as angiography with embolisation may be suggested. A special dye is injected into the bloodstream and X-rays are taken. These X-rays show up the blood vessels (called angiography) and, in this way, doctors can see where the bleeding is coming from. A substance is then injected into the bleeding blood vessel so that it is plugged or 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 recur. Medication to suppress stomach acid may be given to help the tear heal.

What is the outlook (prognosis) for Mallory-Weiss syndrome?

The outlook (prognosis) is generally very good. In up to 9 out of 10 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 recur?

It is not common for Mallory-Weiss syndrome to 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 excessive vomiting for whatever reason.