From the Guidelines
Mallory-Weiss tears and Boerhaave syndrome are distinct esophageal injuries with different management approaches, and the primary distinction lies in their severity and the need for urgent surgical intervention in Boerhaave syndrome. Mallory-Weiss tears are partial-thickness mucosal lacerations at the gastroesophageal junction, typically caused by forceful vomiting or retching, and present with hematemesis after episodes of vomiting or coughing 1. In contrast, Boerhaave syndrome is a full-thickness esophageal rupture, often resulting from an abrupt increase in esophageal pressure during vomiting, and is characterized by severe chest or epigastric pain, subcutaneous emphysema, and Mackler's triad (vomiting, chest pain, and subcutaneous emphysema) 1.
Key Differences in Management
- Mallory-Weiss tears usually heal spontaneously within 48-72 hours with conservative management, including acid suppression with proton pump inhibitors, avoiding NSAIDs, and temporary cessation of oral intake if needed 1.
- Endoscopic intervention with clips or thermal therapy may be required for persistent bleeding in Mallory-Weiss tears 1.
- Boerhaave syndrome, on the other hand, requires immediate surgical consultation, broad-spectrum antibiotics, NPO status, IV fluids, and often surgical repair or placement of esophageal stents due to its high mortality rate of 20-40% 1.
Recent Guidelines and Recommendations
- The World Journal of Emergency Surgery guidelines suggest that diagnostic endoscopy is useful in patients with suspected esophageal perforation and doubtful CT findings, but caution is warranted due to potential risks of enlarging the perforation size and aggravating contamination 1.
- Endoscopic treatment, including clip placement and stent placement, has been shown to be effective in managing esophageal perforations, with success rates of up to 88% and mortality rates as low as 7.5% 1.
- A recent review published in Clinical Gastroenterology and Hepatology highlights the importance of early recognition and management of esophageal perforations, particularly in high-risk procedures such as esophageal dilation and endoscopic mucosal resection 1.
Clinical Implications
- The key distinction between Mallory-Weiss tears and Boerhaave syndrome lies in their severity and the need for urgent surgical intervention in Boerhaave syndrome.
- Clinicians should be aware of the different management approaches for these two conditions and prioritize timely diagnosis and treatment to prevent morbidity and mortality.
- The use of endoscopic treatment, including clip placement and stent placement, should be considered in the management of esophageal perforations, particularly in patients with minimal symptoms and signs of sepsis 1.
From the Research
Mallory-Weiss Tear vs Boerhaave Syndrome
- Mallory-Weiss syndrome is a cause of upper gastrointestinal hemorrhage, resulting from an abrupt rise in abdominal pressure due to nausea or vomiting, inducing a tear near the esophagogastric mucosal junction 2.
- Boerhaave syndrome, on the other hand, is a transmural rupture of the esophagus, often caused by a sudden increase in pressure inside the esophagus, and is a more severe and potentially life-threatening condition 3, 4.
Key Differences
- Location and extent of the tear: Mallory-Weiss tear is typically located on the cardia part of the stomach side and spanning across the esophagogastric mucosal junction, whereas Boerhaave syndrome involves a full-thickness rupture of the esophageal wall 2, 3.
- Severity and mortality: Boerhaave syndrome has a higher mortality rate, ranging from 10 to 50%, compared to Mallory-Weiss syndrome, which often resolves spontaneously or with endoscopic treatment 2, 4.
Relationship Between the Two Conditions
- A Mallory-Weiss syndrome can potentially evolve into a Boerhaave syndrome if left untreated or if further barotraumas occur, as demonstrated in a case report where an untreated Mallory-Weiss syndrome progressed to a fatal Boerhaave syndrome 3.
Diagnosis and Management
- Diagnosis of both conditions requires a combination of clinical presentation, imaging studies, and endoscopic evaluation 5, 4.
- Management of Mallory-Weiss syndrome typically involves endoscopic hemostasis, fasting, and inhibitors of acid secretion, while Boerhaave syndrome requires more aggressive treatment, including surgical intervention, broad-spectrum antibiotics, and supportive care 2, 5, 4.