Mallory-Weiss Tear Causes
Mallory-Weiss tears are mucosal lacerations caused by forceful retching and vomiting that create a sudden increase in intra-abdominal pressure, typically occurring at the gastroesophageal junction. 1
Primary Mechanism
- Forceful retching or vomiting is the fundamental cause, generating acute pressure gradients across the gastroesophageal junction that exceed the tensile strength of the mucosa 1, 2
- Any condition that produces repeated or violent vomiting can precipitate a tear, including diabetic ketoacidosis, thyroid storm, or other metabolic emergencies 3, 4
Major Predisposing Factors
Alcohol-Related
- Chronic alcohol abuse is the classic risk factor, historically accounting for the majority of cases, though recent data show this represents a smaller proportion (only 13 of 190 cases in one series) 5, 6
- Alcoholics experience excessive vomiting episodes that create the mechanical forces necessary for mucosal laceration 7, 6
- Men with chronic alcohol use predominate in fatal cases, with an average age of 48 years 6
Iatrogenic Causes
- Endoscopic procedures now represent the most common cause, accounting for more than half of all cases (100 of 190 patients in recent series) 5
- Esophagogastroduodenoscopy can induce retching or gagging that precipitates tears, particularly in patients with anatomic risk factors 2, 5
Anatomic Risk Factors
- Hiatal hernia increases susceptibility to gastric perforation and atypical tear locations 2
- Atrophic gastritis weakens mucosal integrity 2
- Advanced age (particularly >60 years) compounds risk through reduced tissue resilience 3, 2
High-Risk Clinical Scenarios
- Severe metabolic disturbances creating intense physiologic stress, such as the combination of thyroid storm and diabetic ketoacidosis, markedly elevate risk through stress-related mucosal disease 4
- Cyclic vomiting syndrome produces repeated mechanical trauma 1
- Any cause of persistent nausea and vomiting, including chemotherapy, pregnancy (hyperemesis gravidarum), or gastroenteritis 3
Medication-Related Considerations
- While NSAIDs, aspirin, anticoagulants, and antiplatelet agents do not directly cause Mallory-Weiss tears, they dramatically worsen bleeding severity once a tear occurs 3
- Dual antiplatelet therapy or multiple antithrombotic agents increase the likelihood of massive hemorrhage from what would otherwise be a self-limited tear 3
Common Pitfall
- Do not assume all upper GI bleeding in alcoholics is variceal—Mallory-Weiss tears account for approximately 15% of upper GI bleeding episodes and are frequently the culprit in patients with vomiting preceding hematemesis 4, 6
- The tear itself is an epiphenomenon of the vomiting rather than a primary disease process; identifying and treating the underlying cause of vomiting (metabolic derangement, alcohol withdrawal, etc.) is essential to prevent recurrence 1