Mallory-Weiss Syndrome was first described in 1929 by George Kenneth Mallory and Soma Weiss, two American physicians at Boston City Hospital. They documented the condition in patients who had experienced upper GI bleeding following severe vomiting.
Their work highlighted the mucosal tears at the gastroesophageal junction and led to the eponymous naming of the syndrome.
Unlike Boerhaave Syndrome, where the esophagus ruptures completely, Mallory-Weiss Syndrome involves only a partial tear of the mucosal layer.
This condition is associated with upper gastrointestinal (GI) bleeding and is often self-limiting but can occasionally lead to significant hemorrhage.
Causes and Pathophysiology
Triggered by Severe Vomiting: The syndrome often occurs after repeated vomiting or retching episodes, usually related to alcohol intoxication, eating disorders, or acute gastroenteritis.
Other Causes: Coughing, lifting heavy objects, trauma, convulsions, or anything that increases intra-abdominal pressure.
Pathophysiology: The increased pressure from vomiting causes a longitudinal tear at the gastroesophageal junction, leading to bleeding.
Signs and Symptoms
Patients with Mallory-Weiss syndrome may present with:
- Hematemesis: Vomiting of bright red blood or "coffee-ground" emesis. A hallmark symptom.
- Melena: Black, tarry stools due to digested blood.
- Epigastric or Retrosternal Pain: Pain located in the upper abdomen or chest, which may be mistaken for other conditions like myocardial infarction.
- Signs of Hypovolemia: If bleeding is severe, look for signs such as dizziness, hypotension, pallor, and tachycardia.
- History of Severe Vomiting: Often after binge drinking or an illness causing repeated retching.
EMS Recognition and Prehospital Treatment
Patient Assessment Priorities:
• History Taking: Ask about recent vomiting, alcohol use, or illnesses that might have led to repeated retching.
Inquire about the color and amount of vomitus. Bright red blood is more suggestive of active bleeding, while coffee-ground emesis suggests older blood.
Determine any history of GI bleeding or relevant medical conditions (e.g., peptic ulcer disease, cirrhosis).
• Physical Examination: Assess for signs of hypovolemic shock: tachycardia, hypotension, altered mental status, and pallor.
Perform an abdominal exam to check for tenderness, guarding, or distension.
Check for melena, if possible.
• Differential Diagnosis: Always differentiate MWS from other causes of hematemesis or epigastric pain:
- Peptic Ulcer Disease
- Esophageal Varices (often linked to liver disease)
- Gastric Ulcers or Malignancies
- Boerhaave Syndrome
Patient Management Priorities:
• Airway Management: Ensure the airway is clear. Patients actively vomiting blood are at risk of aspiration.
Position the patient to prevent aspiration (e.g., left lateral recumbent position).
• Circulatory Support: Establish IV access and administer IV fluids (normal saline or lactated Ringer’s) if the patient shows signs of shock.
Monitor for worsening hemodynamic instability.
• Minimize Further Trauma: Advise the patient to avoid any further vomiting, coughing, or retching as it can exacerbate the tear.
Keep the patient NPO (nothing by mouth) to prevent further irritation.
Treat Nausea and Vomiting: If protocols allow, consider administering antiemetics (e.g., ondansetron) via IV to prevent further vomiting, which could worsen the tear.
• Oxygen Therapy: Administer oxygen if the patient has signs of hypoxemia or shock.
• Monitor: Continuously monitor vital signs, including heart rate, blood pressure, and mental status.
• Rapid Transport: Rapid transport to a hospital with endoscopy capabilities is crucial, as definitive diagnosis and management (e.g., endoscopic hemostasis) often require specialist care.
Key Considerations for EMS
• Monitor for Signs of Shock: Patients can quickly decompensate, especially if bleeding is significant.
• Avoid Overly Aggressive Fluid Resuscitation: While fluids are necessary to stabilize blood pressure, overloading can increase bleeding.
• Rapid Transport to Definitive Care: Most Mallory-Weiss tears are diagnosed and treated via endoscopy.
Further Reading:
Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education
Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson
Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education
Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell
Rawla, P., Devasahayam, J. (2023) Mallory-Weiss Syndrome. StatPearls Treasure Island, Florida: StatPearls. Accessed September 20, 2024
Turner, A. R., Collier, S. A., & Turner, S. D. (2023) Boerhaave Syndrome. Treasure Island, Florida: StatPearls. Accessed September 14, 2024
