Vol. XXXVI No.
2 JOURNAL OF VASCULAR NURSING
www.jvascnurs.net
Clinical Column
Overview of Mallory-Weiss syndrome
Kathleen Rich, PhD, RN, CCNS, CCRN-CSC, CNN
Mallory-Weiss syndrome (MWS), also known as Mallory-
Weiss tear(s), is defined as longitudinal, nonperforating mucosal
lacerations in the gastroesophageal junction resulting in upper
gastrointestinal (GI) bleeding.1 It is estimated that WMS is the
cause of 8%–15% of nonvariceal upper GI bleeding.2 This col-
umn will provide an overview of MWS including demographics,
pathogenesis, associated risk factors, presenting symptoms, treat-
ment, and nursing considerations.
DEMOGRAPHICS
MWS was first described in 1929 by Mallory and Weiss3 in
patients experiencing vomiting after binging on alcohol.
Although MWS has been reported in all age groups, the majority
of patients are in their 40s–50s. Males have a higher incidence
than females with a ratio of 2:1–4:1.2 A study by Ljubicic
et al4 revealed a one-year cumulative incidence for MWS
bleeding of 7.3 cases/100,000 persons and an overall 30-day
mortality rate of 5.3%. Pabst et al examined the cause and fre-
quency of upper GI bleeding after infrarenal aortic graft surgery,
with MWS being reported as the cause in 1 out of 74 postopera-
tive bleeding episodes.5
PATHOGENESIS AND RISK FACTORS
Although not completely understood, it is proposed that
the primary mechanism behind the mucosal lacerations is a
sudden, significant increase in intragastric and intraabdominal
pressure that is transmitted to the gastroesophageal junction
and esophagus.2,6 Risk factors include retching, vomiting,
hiccups, blunt abdominal trauma, chest trauma (including
cardiopulmonary resuscitation), coughing, primal scream
therapy, and seizures.2,6 Alcohol use is reported in 30%–60%
From the Franciscan Health – Michigan City, Michigan City,
Indiana.
Corresponding author: Kathleen Rich, PhD, RN, CCNS, CCRN-
CSC, CNN, Critical Care Clinical Nurse Specialist, Franciscan
Health – Michigan City, 301 W. Homer Street, Michigan City,
IN 46360 (E-mail: Kathleen.rich@franciscanalliance.org).
1062-0303/$36.00
Copyright Ó 2018 by the Society for Vascular Nursing, Inc.
https://doi.org/10.1016/j.jvn.2018.04.001
PAGE 91
of patients.2 Iatrogenic causes such as trauma from insertion or
manipulation of a transesophageal echocardiogram probe have
been associated with MWS.7,8 The presence of a hiatal hernia
has been documented as a predisposing factor because it is
present in 40%–80% of MWS patients.2,6 During vomiting, the
transmural pressure gradient is thought to be greater in the
hiatal hernia than that in rest of the stomach, causing the
lacerations. However, an age- and gender-matched study from
a national database report of MWS patients found no significant
difference in the hiatal hernia incidence between the two groups.9
Table 1 summarizes the common risk factors of MWS.
SYMPTOMS AND DIAGNOSIS
An acute onset of hematemesis, that is, either frank red
blood or coffee ground in appearance, is present in the majority
of patients.6,10 This upper GI bleeding is often preceded by an
episode of vomiting, retching, straining, or coughing.2,6
Additional symptoms include back or epigastric pain, melena,
or hematochezia. Signs of shock such as hypotension and
tachycardia may be present depending on the blood loss
volume.2,6,7 Obtaining a medical history to identify for the
presence of risk factors, medication use, and comorbid
conditions assists in differentiating potential bleeding
causes.10 Baseline laboratory tests include a complete blood
count, serum electrolytes, blood urea nitrogen, creatinine liver
function, and coagulation tests to assess the patient’s current
status.2,6,10 Additional diagnostics may be ordered based
on the admitting presentation and medical history. An
esophagogastroduodenoscopy is considered the gold standard
to obtain an accurate diagnosis.2,6,10,11 Figure 1 depicts the
endoscopic appearance of a Mallory-Weiss tear. Use of a risk
stratification scale such as the Rockall scoring system aids the
physician in identifying those patients at risk for adverse out-
comes of rebleeding or death.6,12
TREATMENT
The initial management of any patient with upper GI bleeding
includes assessing for hemodynamic instability, subsequent pa-
tient stabilization with intravenous (IV) fluid resuscitation, and,
if indicated, blood product transfusions.2,6,10 The patient is
kept NPO (nothing by mouth) until bleeding is controlled, and
the endoscopic evaluation is done. Medications that potentiate
bleeding are held. Insertion of a nasogastric tube may be
PAGE 92 JOURNAL OF VASCULAR NURSING
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TABLE 1
RISK FACTORS FOR MALLORY-WEISS
SYNDROME
 Retching and vomiting
 Hiccups
 Coughing
 Primal scream therapy
 Chest wall trauma (including cardiopulmonary
resuscitation)
 Blunt abdominal trauma
 Seizures
 Iatrogenic (e.g. transesophageal echocardiogram)
 Pre-existing hiatal hernia
ordered. Serial monitoring of the hemoglobin and hematocrit
is done. In the majority of patients, bleeding resolves
spontaneously.2,6,11 If indicated, endoscopic treatment options
include one or more of the following: injection therapy
(typically with epinephrine), electrocoagulation, hemoclip, or
band ligation.2,6,11 If the endoscopic treatment is unsuccessful,
angiographic transarterial embolization may be performed.6,13
A laparotomy to oversee the bleeding vessel is often reserved
for uncontrolled or repeated bleeding or failure of the
angiographic intervention.2,6 Recurrent bleeding is more
commonly seen in patients presenting with signs of shock on
arrival to the hospital, a low initial hematocrit, or those with
active bleeding upon endoscopy.6,11 Secondary use of an IV
proton pump inhibitor for acid suppression is prescribed either
twice daily or by continuous infusion depending on the
severity of bleeding and physician preference. A proton pump
inhibitor is felt to promote hemostasis and clot stability by
raising the intragastric pH.10,14 Administration of an IV
Figure 1. Endoscopic appearance of Mallory-Weiss tear with mild
oozing. The tear starts at the gastroesophageal junction (large ar-
row) and extends distally into the hiatal hernia (small arrow).
FIG. 28.5. From Feldman M, et al. Sleisenger and Fordtran’s Gastro-
intestinal and Liver Disease. 10th Ed. Philadelphia: Elsevier; 2016.
JUNE 2018
antiemetic such as ondansetron is ordered in persistent nausea
and vomiting conditions.6
NURSING CONSIDERATIONS
Frequent monitoring of the vital signs and clinical
assessments for signs of hemodynamic instability and continued
bleeding are standard. Prompt physician notification of abnormal
laboratory values or changes in the patient’s condition will assist
in timely administration of IV fluids, medications, and blood
products. If the physician has ordered a nasogastric tube before
the esophagogastroduodenoscopy, insert the tube and perform
gastric lavage to cleanse the stomach.10 Assess for potential
comorbid condition involvement resulting from blood loss,
such as the development of angina due to a low hemoglobin
level.10 Provide patient education including risk factor
modification and counseling referral if there is a history of
alcohol abuse. Incorporate these interventions into the nursing
plan of care.
In patients with continual nausea and vomiting, a sched-
uled rather than PRN (as necessary) antiemetic administration
may be considered. In the hospitalized patient requiring a
surgical procedure, the nurse should be aware of the risk of
MWS developing from postoperative nausea and vomiting
(PONV).15 PONV is defined as any nausea, retching, or
vomiting occurring during the first 24–48 hours after
surgery.16 The reported incidence of PONV is 30% in all
postsurgical patients.15,16 Risk factors include female
gender, nonsmoker, history of PONV or motion sickness,
general anesthesia technique, anesthesia duration, and use of
volatile anesthetics and opioids.15,16 The three classes
of antiemetic drugs, such as serotonin antagonists
(eg, ondansetron), corticosteroids (eg, dexamethasone), and
dopamine antagonists (eg, droperidol), have a similar
efficacy in treating PONV.16 The nurse should be knowledge-
able of potential antiemetic side effects. Vomit is inspected for
signs of blood, and if present, the physician is notified. A
postoperative pain control plan that includes nonsteroidal
anti-inflammatory drugs and other non-opioids to reduce
opioid use will assist in reducing the incidence of PONV.15,16
MWS is a relatively common cause of nonvariceal upper GI
bleeding that occurs in both the community and hospital settings.
The bleeding continuum ranges from spontaneous bleeding
cessation to life-threatening hemorrhage. Hospitalized vascular
patients are at risk for MWS development due to the presence
of underlying risk factors or development of PONV after a surgi-
cal intervention and/or opioid administration. Nursing knowl-
edge of the risk factors, symptoms, diagnosis, and treatment
options will improve the care delivered and assist in preventing
any adverse outcomes.
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795.
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the cardiac orifice of the stomach due to vomiting. Am J
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