01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Forceful retching sharply raises intragastric pressure against a relatively negative thoracic pressure. When the gastro-oesophageal junction fails to relax or moves through the hiatus, the mucosa splits longitudinally, most often on the gastric side of the junction. The lesion remains superficial compared with Boerhaave syndrome, but it can expose submucosal vessels and cause brisk haemorrhage.
Diagnosis rests on endoscopy after resuscitation. A linear laceration with fresh bleeding, visible vessel or adherent clot supports the cause, but the endoscopist must inspect for coexisting peptic ulcer, varices, tumour or portal hypertensive disease. A story of retching is not diagnostic; vomiting can also be the first manifestation of another lesion that subsequently bleeds.
Most tears stop bleeding with supportive care and treatment of the vomiting trigger. The ESGE-endorsed CAG 2025 non-peptic-ulcer guideline conditionally suggests endoscopic treatment of an actively spurting or oozing tear, with band ligation or through-the-scope clips preferred over adrenaline injection alone; either mechanical method is reasonable when technically feasible. It conditionally suggests against haemostatic endotherapy for a non-bleeding visible vessel, adherent clot, flat pigmented spot or clean base in a tear. These recommendations have very low certainty and still require individual clinical assessment. ESGE 2015 separately supports PPI treatment for a tear without active bleeding; the 2025 endotherapy document does not specify a PPI course. Do not automatically import the high-dose peptic-ulcer infusion into a quiet tear. Secondary prevention addresses nausea, alcohol exposure, ulcerogenic medicines and recurrent-bleeding advice.
Key points
- A Mallory-Weiss lesion is a longitudinal mucosal laceration at or near the gastro-oesophageal junction produced by a sudden pressure gradient during retching or vomiting.
- The classic sequence is non-bloody vomiting followed by haematemesis, but cough, seizures, childbirth or other abrupt strain can precipitate the tear.
- CAG 2025 conditionally supports band ligation or through-the-scope clips for actively oozing/spurting tears and suggests against endotherapy for a non-bleeding vessel, adherent clot, flat spot or clean base. Evidence certainty is very low; a peptic-ulcer vessel rule must not be imported.
- Assess airway, circulation and Glasgow-Blatchford risk before assigning a benign label; urgent endoscopy both confirms the lesion and excludes ulcer or varices.
- Severe chest pain, neck crepitus, fever or systemic deterioration after vomiting raises concern for Boerhaave perforation; obtain urgent CT and surgical assessment instead of treating the episode as a superficial mucosal tear.
- ESGE 2015 separately supports PPI treatment for a tear without active bleeding; the current CAG endotherapy guidance supplies no PPI dose. A high-dose ulcer infusion is not automatic, and discharge needs stable observations, oral tolerance and explicit rebleeding advice.
- Alcohol exposure is common because it promotes vomiting and mucosal injury, but its absence neither excludes the diagnosis nor proves another cause.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Forceful retching
Abrupt repetitive abdominal contraction raises intragastric pressure against the thorax and stretches junctional mucosa until it splits.
Predisposing vomiting triggers
Alcohol excess, gastroenteritis, pregnancy, coughing, seizures or anaesthesia can generate repeated pressure surges that initiate a laceration.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Pressure gradient
During forceful retching, a sudden high gastric-to-thoracic pressure difference shears longitudinal mucosal fibres at the mobile gastro-oesophageal junction.
- 2Submucosal vessel exposure
The split reaches vascular submucosa without traversing the entire wall, allowing oozing or arterial bleeding into the lumen.
- 3Spontaneous tamponade
Reduced retching and local clot formation allow many superficial lacerations to stop bleeding without an endoscopic intervention.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Several episodes of non-bloody vomiting followed by fresh haematemesis is characteristic but not pathognomonic.
Endoscopy shows a linear mucosal split crossing or immediately adjacent to the gastro-oesophageal junction.
Actual spurting or oozing from the tear supports endoscopic haemostasis. A non-bleeding visible vessel or adherent clot is a different category: CAG 2025 suggests against endotherapy in these tears, unlike a peptic-ulcer visible vessel.
Severe chest pain, dyspnoea, crepitus or sepsis after vomiting suggests full-thickness rupture.
Binge drinking can provoke repeated vomiting, coagulopathy and poor follow-up, each modifying bleeding risk and discharge planning.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Upper-GI endoscopyFirst step - Why
- Confirm the tear, grade active bleeding and exclude other upper-GI sources.
- Interpretation and limitations
- Record exact junctional location, stigma and therapy; absence of active bleeding often permits conservative management.
- 02
Glasgow-Blatchford score - Why
- Estimate intervention need before endoscopy.
- Interpretation and limitations
- Use objective urea, haemoglobin, pressure, pulse and clinical variables rather than downgrading risk from the presumed diagnosis.
- 03
Full blood count and coagulation - Why
- Quantify blood loss, platelets and haemostatic disturbance.
- Interpretation and limitations
- Serial haemoglobin and physiology are more informative than one early concentration after acute loss.
- 04
CT chest with appropriate contrast - Why
- Investigate suspected transmural oesophageal rupture or mediastinal contamination.
- Interpretation and limitations
- Extraluminal gas, fluid or contrast redirects care from endoscopic mucosal haemostasis to urgent perforation management.
- 05
Liver profile and alcohol assessment - Why
- Identify coagulopathy, portal hypertension risk and a vomiting driver.
- Interpretation and limitations
- Abnormal liver tests do not prove varices; endoscopy still defines the source and guides treatment.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Bleeding peptic ulcer
A gastric or duodenal ulcer can produce identical haematemesis and may itself provoke nausea, so endoscopy must inspect beyond the junction.
Oesophageal varices
Portal hypertensive veins cause potentially massive bleeding and require vasoactive, antibiotic and band-ligation pathways distinct from a mucosal tear.
Boerhaave syndrome
Full-thickness oesophageal rupture after vomiting produces severe chest pain, extraluminal gas and sepsis rather than an isolated mucosal bleed.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01Active bleeding tearControl the vessel and reassess riskFirst stepA 48-year-old has repeated retching followed by 500 mL fresh haematemesis, transient hypotension and endoscopy showing an actively oozing junctional laceration.+
- 1Resuscitate circulation, protect the airway from recurrent blood and calculate risk without assuming the tear will self-seal.
- 2At urgent endoscopy, exclude varices and peptic ulcer. CAG 2025 conditionally supports band ligation or through-the-scope clips for active tear bleeding, favouring these over adrenaline alone, with very low certainty. The operator can position clips across this laceration and applies them until oozing stops.
- 3Treat nausea, review antithrombotics and alcohol exposure and use post-endoscopic acid suppression according to the bleeding plan.
- 4Verify control with stable pulse and haemoglobin and no recurrent haematemesis or melaena during observation; provide immediate return advice at discharge.
02Non-bleeding lesionUse conservative care after visual proofAlternativeA stable patient has self-limited haematemesis. Endoscopy shows a Mallory-Weiss tear with a non-bleeding visible vessel, no oozing or spurting and no alternative lesion.+
- 1Confirm bleeding has stopped, repeat the haemodynamic assessment and document that the vessel belongs to a tear rather than a peptic ulcer. Under the conditional CAG 2025 recommendation, do not clip or band this non-bleeding vessel merely because it is visible.
- 2Use supportive care, manage the vomiting trigger and consider PPI treatment under the separate ESGE 2015 non-active-bleeding recommendation. Reassess clinical risk rather than applying the ulcer-infusion regimen or a routine endotherapy rule to this tear.
- 3During observation there is no further haematemesis, pulse and haemoglobin remain stable, and supervised oral fluids are tolerated after nausea settles. The history identifies a resolving vomiting illness rather than continuing alcohol or medicine exposure.
- 4The senior team agrees discharge after that observed recovery, with recurrent bleeding, fainting, severe chest pain and swallowing-difficulty instructions and a documented follow-up contact. New bleeding would prompt fresh assessment of haemostasis rather than reliance on the earlier quiet appearance.
03Chest pain after vomitingSeparate mucosal from transmural injuryAfter violent vomiting, a patient develops severe chest pain, tachycardia and neck crepitus with little haematemesis.+
- 1Keep nil by mouth, start sepsis assessment and involve upper-GI or thoracic surgery urgently.
- 2Obtain CT rather than assuming a superficial tear from the vomiting history.
- 3Treat confirmed perforation with drainage, antimicrobials and repair or stenting according to anatomy.
- 4Document the distinction because endoscopic tear care alone would leave mediastinal contamination uncontrolled.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Haemorrhagic shock
Ongoing laceration bleeding can reduce circulating volume, impair organ perfusion and require transfusion and urgent endoscopic haemostasis.
Aspiration
Active vomiting of blood can contaminate the airway, particularly when consciousness is reduced by shock, sedation or alcohol.
Rebleeding
Clot disruption, persistent vomiting or impaired haemostasis can restart luminal blood loss after an apparently quiet initial examination.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Repeat pulse, pressure, haemoglobin and evidence of fresh haematemesis or melaena after initial control.
- Monitor airway and oxygenation when vomiting, sedation or alcohol intoxication increases aspiration risk.
- Record the endoscopic stigma and precise haemostatic method for any rebleeding handover.
- Review antiemetic response and oral tolerance before discharge.
- Arrange alcohol, pregnancy, gastrointestinal or medicine follow-up according to the vomiting cause.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
The tear is mucosal
Mallory-Weiss bleeding can be brisk, but mediastinal contamination points to full-thickness Boerhaave rupture instead.
Retching is not exclusive
A peptic ulcer or varix can bleed during vomiting, so the sequence never replaces endoscopic source identification.
Active status changes treatment
A clean non-bleeding tear usually needs support, while visible ongoing blood justifies endoscopic haemostasis.
Vomiting cause prevents recurrence
Stopping bleeding without controlling nausea, alcohol exposure or another trigger leaves the pressure mechanism active.
11Common pitfallsFrequent interpretation and management errors.
- 01
Calling all post-retch haematemesis Mallory-Weiss without endoscopic source assessment.
- 02
Under-resuscitating active bleeding because most tears are self-limiting.
- 03
Missing Boerhaave syndrome in a patient whose dominant symptom is severe chest pain.
- 04
Discharging without addressing the cause of recurrent vomiting or harmful alcohol use.