What is the difference between Mallory-Weiss tear and Boerhaave syndrome?

Mallory-Weiss Tear vs. Boerhaave Syndrome: Key Differences

Mallory-Weiss tear and Boerhaave syndrome are distinct esophageal injuries that differ primarily in depth of tear, clinical presentation, and management approaches, with Boerhaave syndrome being a full-thickness perforation requiring urgent intervention while Mallory-Weiss is a mucosal tear that often resolves spontaneously.

Anatomical Differences

Mallory-Weiss Tear

• Partial, non-transmural mucosal laceration occurring at or near the esophagogastric junction 1, 2
• Limited to the mucosa and submucosa layers
• Typically longitudinal in orientation
• Most commonly affects the gastroesophageal junction 2

Boerhaave Syndrome

• Full-thickness (transmural) rupture of the esophagus 3, 4
• Involves all layers of the esophageal wall
• Most commonly affects the lower third of the esophagus 5
• Results in leakage of esophageal contents into the mediastinum or pleural cavity 3

Etiology and Mechanism

Mallory-Weiss Tear

• Commonly associated with forceful vomiting or retching
• Occurs in 3-10% of cases of upper gastrointestinal bleeding 2
• Can occur with any condition causing increased abdominal pressure
• Often associated with alcohol consumption 6

Boerhaave Syndrome

• Typically results from forceful vomiting with increased intra-abdominal pressure 4
• Accounts for approximately 15% of all esophageal perforations 5
• More common in middle-aged adults, especially after food or alcohol indulgence 4
• Eosinophilic esophagitis is now recognized as an important cause of spontaneous perforation 3

Clinical Presentation

Mallory-Weiss Tear

• Typically presents with hematemesis after vomiting
• Classical history of non-bloody emesis followed by hematemesis (only in 29% of cases) 6
• Most common presentation is blood with the first vomiting episode 6
• Usually mild bleeding that often stops spontaneously 2
• Rarely causes severe hemodynamic compromise

Boerhaave Syndrome

• Presents with sudden onset of severe chest or abdominal pain following forceful vomiting 5, 4
• Additional symptoms include dyspnea and signs of sepsis in later stages 5
• Can present with subcutaneous emphysema, pneumomediastinum, and pleural effusion 3
• More severe presentation with signs of sepsis if diagnosis is delayed
• Can lead to significant morbidity and mortality (10-50%) 4

Diagnostic Approach

Mallory-Weiss Tear

• Diagnosed primarily by upper gastrointestinal endoscopy 2
• Endoscopy shows longitudinal mucosal tear at the esophagogastric junction 2
• Usually no need for additional imaging studies

Boerhaave Syndrome

• Contrast-enhanced CT and CT esophagography are recommended with high sensitivity (92-100%) 3, 5
• Radiographic findings include:
  • Pneumomediastinum
  • Pleural effusion
  • Subcutaneous emphysema
  • Pneumothorax 5
• Diagnostic delay beyond 24 hours significantly increases mortality 5

Management

Mallory-Weiss Tear

• Most cases (approximately 87.5%) resolve with conservative management 7
• Endoscopic treatment indicated only for active bleeding or stigmata of recent bleeding 2
• Treatment options include:
  • Injection therapy
  • Argon plasma coagulation
  • Hemoclip placement
  • Band ligation (appears most effective) 1, 2
• Proton pump inhibitors and antiemetics are commonly used 2

Boerhaave Syndrome

• Requires urgent intervention due to high mortality risk
• Management options depend on extent of perforation:
  • Surgical repair for large perforations
  • Conservative management for contained perforations
  • Endoscopic interventions (clips, stents) for selected cases 5
• CT contrast study should be performed to assess degree of extravasation 3
• Multidisciplinary team approach involving gastroenterologist, surgeon, radiologist, and dietitian 3

Prognosis

Mallory-Weiss Tear

• Excellent prognosis with low mortality
• Bleeding stops spontaneously in most cases 6
• Recurrence is rare

Boerhaave Syndrome

• Mortality rate between 10-50% 4
• Prognosis heavily dependent on time to diagnosis and treatment
• Delayed diagnosis (>24 hours) significantly worsens outcomes 5

Common Pitfalls and Caveats

1. Mistaking Boerhaave syndrome for a Mallory-Weiss tear can be fatal due to delayed appropriate intervention
2. Not all patients with Mallory-Weiss tear have the classical history of vomiting followed by hematemesis
3. Boerhaave syndrome can present atypically, especially in younger patients 4
4. Both conditions can occur after forceful vomiting, making clinical differentiation challenging
5. In patients with esophageal perforation, it's important to understand the differences between EoE perforation and Boerhaave syndrome, as their treatment and outcomes differ significantly 3