Can intubation from anesthesia cause a Mallory-Weiss tear, especially in patients with pre-existing gastrointestinal conditions or other risk factors for increased intra-abdominal pressure?

Can Intubation from Anesthesia Cause Mallory-Weiss Tear?

Yes, intubation and anesthesia can cause Mallory-Weiss tears, though this is uncommon and typically occurs through indirect mechanisms related to the procedure rather than direct trauma from the endotracheal tube itself.

Mechanisms of Mallory-Weiss Tear During Anesthesia

The primary mechanism involves increased intra-abdominal and intragastric pressure during the perioperative period, not direct injury from the endotracheal tube:

• Gastric distention from mask ventilation during induction can significantly increase intragastric pressure, particularly if excessive ventilation pressures are used or if cricoid pressure is applied 1
• Retching, coughing, or struggling during induction or emergence creates sudden pressure spikes across the gastroesophageal junction that can tear the mucosa 2, 3
• Gastric inflation during endoscopic procedures under general anesthesia has been documented to cause Mallory-Weiss tears and even gastric perforation, as reported in a case where esophageal endoscopic submucosal dissection under general anesthesia resulted in gastric perforation at a Mallory-Weiss tear site 4, 3

High-Risk Clinical Scenarios

Certain anesthesia situations substantially increase the risk:

• Difficult or prolonged intubation attempts with repeated laryngoscopy, gagging, and retching dramatically elevate risk 5
• Inadequate depth of anesthesia allowing patient movement, coughing, or retching during instrumentation 3
• Emergency surgery with full stomach (such as bowel obstruction) where gastric distention is already present and rapid sequence induction may involve forceful mask ventilation 5, 6
• Excessive cricoid pressure (>30 N) can trigger retching and vomiting, paradoxically causing the aspiration event it aims to prevent 2

Evidence from Clinical Cases

The literature documents several relevant scenarios:

• A case report describes a patient who developed a large Mallory-Weiss tear with major gastrointestinal bleeding following PCI, which occurred in the perioperative period and led to stent thrombosis when antiplatelet therapy was interrupted 1
• Multiple case reports document Mallory-Weiss tears occurring during esophageal endoscopic procedures under general anesthesia, attributed to gastric inflation despite adequate sedation and absence of retching 4, 3
• One case series noted that a solitary patient developed an iatrogenic Mallory-Weiss tear during routine upper gastrointestinal endoscopy 7

Critical Preventive Measures

To minimize risk during anesthesia and intubation:

• Ensure adequate depth of anesthesia before laryngoscopy to prevent coughing, gagging, or retching 3
• Use gentle mask ventilation with minimal pressures (ideally <15 cm H₂O) to avoid gastric inflation, particularly during rapid sequence induction 1, 5
• Insert nasogastric tube for gastric decompression in high-risk patients (bowel obstruction, gastroparesis) before induction to reduce intragastric pressure 1, 5
• Limit cricoid pressure force to 10 N in awake patients and 30 N after loss of consciousness, and release immediately if it triggers retching or makes intubation difficult 2
• Minimize procedure time and air/water insufflation during endoscopic procedures under anesthesia 3

Clinical Significance and Management

While Mallory-Weiss tears from intubation are uncommon, they can have serious consequences:

• Most Mallory-Weiss tears (approximately 85%) stop bleeding spontaneously and require only supportive care 8, 9, 7
• However, active bleeding or visible vessels require endoscopic intervention, with multipolar electrocoagulation, hemoclipping, or band ligation being effective treatment modalities 8, 9
• The case described earlier demonstrates that major bleeding from a Mallory-Weiss tear in the perioperative period can necessitate interruption of critical medications (such as antiplatelet therapy), potentially leading to catastrophic complications like stent thrombosis 1

Important Caveats

• The endotracheal tube itself does not directly cause Mallory-Weiss tears—these tears occur at the gastroesophageal junction, not in the trachea or proximal esophagus where the tube passes 8, 9, 7
• Nearly half of patients with Mallory-Weiss tears have no antecedent symptoms of nausea, retching, or vomiting, making it difficult to predict which patients are at risk 7
• Patients with pre-existing gastrointestinal dysmotility (such as those with Duchenne muscular dystrophy or bowel obstruction) have increased baseline risk due to gastroparesis and increased intra-abdominal pressure 1, 5