What is the difference between Mallory-Weiss syndrome and Boerhaave's syndrome, and how are they diagnosed?

Mallory-Weiss vs Boerhaave Syndrome: Key Differences and Diagnosis

Critical Distinction

Mallory-Weiss syndrome is a partial-thickness mucosal tear at the gastroesophageal junction that causes upper GI bleeding but is self-limiting in >90% of cases, while Boerhaave syndrome is a catastrophic full-thickness esophageal rupture with 10-20% mortality that requires immediate surgical consultation. 1, 2

Fundamental Differences

Mallory-Weiss Syndrome

• Depth of injury: Partial-thickness tear involving only the mucosa and submucosa at the gastroesophageal junction 3, 4
• Size: Longitudinal mucosal laceration, typically smaller 3
• Primary manifestation: Upper gastrointestinal bleeding (hematemesis and melena) 5, 6
• Severity: Self-limiting in >90% of cases with spontaneous cessation of bleeding 2, 6
• Mortality: Overall 2.7% in-hospital mortality 6
• Contamination: No mediastinal or pleural contamination occurs 1

Boerhaave Syndrome

• Depth of injury: Full-thickness rupture through all layers of the esophageal wall 1, 4
• Size: Large defect (3-8 cm) typically in the left posterolateral wall of the distal esophagus 1
• Primary manifestation: Chest pain (70%), fever (50%), dyspnea (25%), and subcutaneous emphysema (19%) 1, 7
• Severity: Life-threatening emergency with massive contamination of the thorax with air and digestive contents 1
• Mortality: 10-20% overall, increasing exponentially if treatment delayed beyond 24 hours 1, 7
• Contamination: Extensive mediastinal and pleural contamination with development of sepsis 1, 7

Diagnostic Approach

For Mallory-Weiss Syndrome

• Gold standard: Upper gastrointestinal endoscopy performed rapidly after first hematemesis 3
• Endoscopic findings: Longitudinal mucosal tear at the esophagogastric junction, with or without active bleeding 3
• Clinical context: History of forceful vomiting or retching followed by hematemesis 8, 3
• Associated findings: Frequently associated with hiatus hernia (up to 15% of upper GI bleeds) 8, 2
• Radiology: Limited diagnostic value unless selective angiography is performed 8

For Boerhaave Syndrome

• Gold standard: Contrast-enhanced CT with 92-100% sensitivity—perform immediately when suspected 1, 7
• Critical imaging findings:
  • Pneumomediastinum 1, 7
  • Pneumothorax (typically left-sided) 1, 7
  • Pleural effusion (left-sided) 1, 7
  • Subcutaneous emphysema 1, 7
  • Air under the diaphragm 1, 7
• CT esophagography: Confirms diagnosis and shows location and extent of perforation 1
• Critical vital sign: Tachycardia is the most important warning sign that should raise immediate suspicion 1, 7
• Warning signs requiring immediate imaging:
  • Persistent (not transient) chest pain after vomiting 1, 7
  • Development of shock (pulse >100 bpm and systolic BP <100 mmHg) 1, 7
  • Rapid clinical deterioration suggesting mediastinal contamination 1, 7

Critical Clinical Pitfall

A Mallory-Weiss tear can evolve into Boerhaave syndrome if further barotrauma occurs before healing. 4 This represents a spectrum of disease rather than distinct entities—if a patient with known or suspected Mallory-Weiss develops chest pain, fever, dyspnea, or subcutaneous emphysema, immediately obtain contrast-enhanced CT to rule out progression to full-thickness rupture 4.

Management Implications

Mallory-Weiss

• Conservative management in most cases (>90% self-limiting) 2, 6
• Endoscopic hemostasis only if active bleeding or signs of recent bleeding at endoscopy 3
• Band ligation is most efficient for primary hemostasis when intervention needed 3
• Endoscopic injection (13.7%) and clipping (12.8%) are commonly used 6

Boerhaave

• Time-critical emergency: Treatment within 24 hours is the most important survival predictor 1, 9
• Requires immediate multidisciplinary team (GI surgeon, gastroenterologist, radiologist) 1
• Often requires surgical intervention given large defect size (3-8 cm) 1

High-Risk Features for Poor Outcomes

Mallory-Weiss

• Hypovolemic shock, acute kidney injury, sepsis, artificial ventilation, ARDS, bleeding anemia, and female sex associated with worse prognosis 6
• Cirrhotic patients have particularly poor outcomes regardless of treatment 2

Boerhaave

• Delay in diagnosis >24 hours exponentially increases mortality 1, 9
• Over 50% of cases have delayed diagnosis due to atypical presentation 1