Mallory-Weiss and Boerhaave Syndromes
On this page
Direct answer
Mallory-Weiss syndrome is a longitudinal mucosal tear at the oesophagogastric junction, usually after forceful retching or vomiting, and most episodes stop bleeding on their own. Boerhaave syndrome is a full-thickness rupture of the distal oesophagus after similar vomiting, classically on the left posterolateral wall. The key distinction is mucosal versus transmural injury, and Boerhaave carries high mortality when repair is delayed.
What you must remember
- Mallory-Weiss tear: a longitudinal mucosal laceration, typically at the oesophagogastric junction, caused by a sudden rise in intra-abdominal and intrathoracic pressure.
- Predisposing factors: alcohol intoxication, binge vomiting, hyperemesis and a hiatus hernia are the commonly listed associations.
- Bleeding in Mallory-Weiss: most episodes stop spontaneously, and endoscopic clips or adrenaline injection are reserved for persistent haemorrhage.
- Boerhaave syndrome: a full-thickness rupture of the distal oesophagus, usually the left posterolateral wall, from raised intraluminal pressure against a closed glottis.
- Mackler triad: vomiting, followed by chest pain and subcutaneous emphysema, which is often incomplete at presentation.
- Hamman sign: a crunching sound on auscultation, synchronous with the heartbeat, that signals mediastinal emphysema and is not always present.
- Diagnostic contrast: a water-soluble iodinated contrast study comes first, because barium that leaks into the mediastinum causes severe inflammation.
- Treatment of Boerhaave: nil by mouth, broad-spectrum antibiotics, drainage and primary surgical repair, ideally within 24 hours.
A diagnostic pathway for chest pain after vomiting
Start with the patient's stability, then match the pattern of injury to the right test. Boerhaave is a surgical emergency, so the pathway moves quickly once a leak is suspected.
- Stabilise first: Check airway, breathing and circulation, and treat significant haematemesis with two large-bore cannulas and resuscitation. Hypotension after vomiting raises the concern for a leak.
- Recognise the pattern: Streaks of blood after retching suggest Mallory-Weiss, while chest pain with subcutaneous emphysema or pneumomediastinum suggests Boerhaave.
- Order the right contrast study: Start with a water-soluble contrast swallow, and use CT with oral contrast if the swallow is negative but suspicion persists.
- Use endoscopy with caution: Endoscopy diagnoses a Mallory-Weiss tear, but it is performed cautiously or avoided when Boerhaave is suspected, because insufflation can enlarge the tear.
- Treat by pattern: Mallory-Weiss usually settles with supportive care, and Boerhaave needs antibiotics, drainage and surgical repair without delay.
Where the exam tries to catch you
The exam tests whether you separate a self-limiting mucosal tear from a life-threatening perforation.
- Trap: choosing barium swallow for suspected Boerhaave Correct: water-soluble contrast is used, because barium that leaks into the mediastinum causes severe inflammation that is hard to treat.
- Trap: labelling every vomiting-related bleed as Boerhaave Correct: Mallory-Weiss is far more common and usually stops bleeding without surgery.
- Trap: waiting for the full Mackler triad before imaging Correct: the triad is often incomplete, so chest pain after vomiting with subcutaneous emphysema needs urgent investigation.
- Trap: managing delayed Boerhaave conservatively as a chest infection Correct: the leak causes mediastinitis and sepsis, and outcome worsens steeply with delay.
Frequently asked questions
What is the difference between Mallory-Weiss syndrome and Boerhaave syndrome?
Mallory-Weiss syndrome is a mucosal tear that usually bleeds and then stops, whereas Boerhaave syndrome is a full-thickness rupture of the oesophagus. Boerhaave is a surgical emergency that causes mediastinitis, and its outcome depends heavily on how quickly repair is done.
Which contrast study is preferred for suspected Boerhaave syndrome?
Water-soluble iodinated contrast is preferred for suspected Boerhaave syndrome, because it leaks without causing a severe mediastinal reaction. Barium is avoided because a leak into the mediastinum is difficult to clear and provokes marked inflammation.
What is the treatment for bleeding from a Mallory-Weiss tear?
Most Mallory-Weiss tears stop bleeding spontaneously, so management is supportive with fluids, transfusion if needed and acid suppression. Endoscopic clips or adrenaline injection are reserved for bleeding that persists despite these measures.
Why does Boerhaave syndrome usually affect the left lower oesophagus?
The left posterolateral wall of the distal oesophagus is the classic site of rupture in Boerhaave syndrome. It is where the forces of vomiting against a closed glottis are typically described to act, so the tear usually occurs there.
What is Hamman sign?
Hamman sign is a crunching sound heard over the precordium that is synchronous with the heartbeat, caused by mediastinal emphysema. It is a classic bedside clue in Boerhaave syndrome, but it is not always present.