Synopsis
Recognise retch-induced mucosal laceration, grade haemorrhage without assuming it is minor, use endoscopic haemostasis for active bleeding and address vomiting, alcohol exposure and competing causes.
- 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.
Key red flags
Haemodynamic instability, repeated fresh haematemesis, syncope or falling haemoglobin cannot be dismissed because bleeding followed retching.
Severe chest pain, subcutaneous emphysema, fever or pleural contamination after vomiting suggests transmural Boerhaave perforation rather than a mucosal tear.
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.
Investigation priorities
Confirm the tear, grade active bleeding and exclude other upper-GI sources.
Management branches
A 48-year-old has repeated retching followed by 500 mL fresh haematemesis, transient hypotension and endoscopy showing an actively oozing junctional laceration.
- Resuscitate circulation, protect the airway from recurrent blood and calculate risk without assuming the tear will self-seal.
- At 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.
A 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.