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Gastroenterology & Nutrition

Mallory-Weiss syndrome

Mallory-Weiss syndrome is an upper-GI bleed from a longitudinal mucosal tear at the gastro-oesophageal junction, classically causing haematemesis after forceful vomiting or retching; most tears stop spontaneously, but the patient still needs acute upper-GI-bleed risk assessment.

In a nutshell

Mallory-Weiss syndrome is a mucosal tear at the gastro-oesophageal junction caused by forceful vomiting or retching. The classic sequence is non-bloody vomiting followed by haematemesis. Most tears stop spontaneously, but every haematemesis presentation needs acute upper-GI-bleed assessment, Glasgow-Blatchford risk scoring and appropriate endoscopy. Severe chest pain or surgical emphysema after vomiting suggests Boerhaave syndrome, not a simple tear.

Classic presentation

After repeated vomiting, a patient begins vomiting fresh blood but is otherwise stable; the bleed is usually self-limiting, although anticoagulation, liver disease or ongoing haematemesis increases risk.

Key points

  • Mallory-Weiss is a mucosal tear; Boerhaave is full-thickness oesophageal rupture.
  • Classic history: non-bloody vomiting or retching first, then haematemesis.
  • Calculate the Glasgow-Blatchford score at presentation for acute upper-GI bleeding.
  • NICE supports considering early discharge at GBS 0; the BSG-led bundle supports considering outpatient management at GBS 0 or 1, but clinical stability and local pathway still decide.
  • Endoscopy is immediate after resuscitation if unstable with severe bleeding and within 24 hours for other admitted upper-GI bleeds.
  • Most tears stop spontaneously; treat active or high-risk bleeding endoscopically and do not use adrenaline alone for non-variceal bleeding.
  • Recurrent bleeding after endoscopic therapy needs repeat endoscopy, then interventional radiology or surgery if necessary.
  • Do not routinely give tranexamic acid for acute GI bleeding.

First-line investigation

Haemodynamic assessment, FBC/U&E/liver tests/coagulation/group-and-save and Glasgow-Blatchford score, followed by endoscopy according to the acute upper-GI-bleed pathway.

Management

Stabilise and exclude perforation

  • Assess airway and circulation, monitor observations, obtain IV access and activate major-haemorrhage/critical-care support if unstable; severe chest pain or surgical emphysema after vomiting requires urgent Boerhaave assessment.3,2,1

Risk-stratify the upper-GI bleed

  • Calculate the Glasgow-Blatchford score and use the current NICE/BSG low-risk thresholds only within a clinically stable, safe local outpatient pathway.3,2

Confirm with appropriately timed endoscopy

  • Perform endoscopy immediately after resuscitation in unstable severe bleeding and within 24 hours for other admitted upper-GI bleeds; a tear that has stopped bleeding may need no specific haemostasis.3,2

Treat active bleeding and rebleeding

  • Use endoscopic clipping or thermal therapy for active/high-risk bleeding, never adrenaline monotherapy; repeat endoscopy for rebleeding, then involve interventional radiology or surgery if haemostasis fails.3,4

Address vomiting and safety-net

  • Treat the precipitant, review antithrombotic management with the relevant specialist and give urgent return advice for recurrent haematemesis, melaena, syncope, worsening pain, dyspnoea, fever or inability to drink.3,5,1

Exam traps

  • The initial vomiting is usually non-bloody; haematemesis after retching is the classic temporal clue.
  • A normal initial haemoglobin does not exclude significant acute blood loss.
  • Do not discharge because the tear seems likely before calculating risk and confirming bleeding has stopped.
  • Do not confuse a mucosal Mallory-Weiss tear with Boerhaave syndrome when severe chest pain, emphysema or sepsis is present.
  • Adrenaline is not recommended as monotherapy for non-variceal upper-GI bleeding.
  • Tranexamic acid is not routine treatment for acute GI bleeding after HALT-IT and current BSG advice.

Illustrations

Mallory-Weiss tear at the gastro-oesophageal junctionAn endoscopic image showing a single longitudinal mucosal tear at the gastro-oesophageal junction, with labels distinguishing the superficial tear from the surrounding normal mucosa.Samir, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. TeachMeSurgery, Oesophageal tears (UK medical education page; Mallory-Weiss tears and Boerhaave differentiation)Updated 1 Jan 2026
  2. BSG-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding (Frontline Gastroenterology 2020; care bundle for the first 24 hours)Updated 1 Jan 2020
  3. NICE CG141, Acute upper gastrointestinal bleeding in over 16s: management (Recommendations updated 25 August 2016; current recommendations include risk scoring and endoscopy timing)Updated 25 Aug 2016
  4. BSG Endoscopy Committee, Non-variceal upper gastrointestinal haemorrhage: guidelines (Gut 2002;51(Suppl 4):iv1; Mallory-Weiss tears and endoscopic haemostasis)Updated 1 Jan 2002
  5. BSG/ESGE guideline update: endoscopy in patients on antiplatelet or anticoagulant therapy (Gut 2021;70:1611-1628; acute GI haemorrhage and antithrombotic interruption/resumption)Updated 1 Sept 2021
  6. BSG/ACPGBI position on tranexamic acid in upper and lower GI bleeding (Position following HALT-IT: do not routinely use tranexamic acid in acute GI bleeding)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.