How should an adult with a Mallory‑Weiss tear presenting with acute upper gastrointestinal bleeding after forceful vomiting be managed?

Management of Mallory-Weiss Tears

Most adults with Mallory-Weiss tears presenting after forceful vomiting can be managed conservatively with intravenous fluid resuscitation and close monitoring, as approximately 75% stop bleeding spontaneously without any intervention. 1

Initial Risk Stratification

Immediately assess hemodynamic status to determine management pathway:

• Check vital signs for shock indicators: pulse >100 bpm and systolic blood pressure <100 mmHg signify high-risk bleeding requiring urgent endoscopy 1
• Hemodynamically stable patients (normal vital signs) can proceed with conservative management and scheduled endoscopy within 24 hours 2
• Target mean arterial pressure >65 mmHg during resuscitation while avoiding fluid overload 1

The Rockall scoring system categorizes Mallory-Weiss tears as low-risk lesions with excellent prognosis overall 1. However, mortality risk increases dramatically with age—rare in patients <40 years but approaching 30% in those >90 years—and is almost exclusively seen in patients with serious comorbidities such as cardiac failure, ischemic heart disease, renal failure, liver failure, or disseminated malignancy 1.

Conservative Management (First-Line for Stable Patients)

For hemodynamically stable patients without active bleeding:

• Establish IV access and begin fluid resuscitation with crystalloid solutions 1
• Monitor vital signs hourly on a general medical ward 1
• Initiate oral liquids and advance to regular diet within 24 hours once deemed safe 2, 1
• Perform endoscopy within 24 hours to confirm diagnosis and assess bleeding risk 2
• Consider early discharge after successful endoscopy showing no stigmata of recent hemorrhage (clean base, no active bleeding) 2, 1

This conservative approach is supported by evidence showing that 75% of Mallory-Weiss tears cease bleeding spontaneously 1, and the majority of patients require no intervention beyond hemodynamic support 3.

Endoscopic Therapy (For Active or High-Risk Bleeding)

Endoscopic intervention is indicated when:

• Active bleeding is visualized at the time of endoscopy 1
• Stigmata of recent hemorrhage are present (visible vessel, adherent clot) 1
• Hemodynamic instability persists despite adequate fluid resuscitation 1

Endoscopic Treatment Options

Multiple effective modalities are available, with selection based on physician expertise and clinical scenario:

• Adrenaline injection (1:10,000 solution) around the bleeding point achieves primary hemostasis in up to 95% of cases 1
• Thermal modalities including heater probe (20-30 J) or argon plasma coagulation are comparable in effectiveness to adrenaline injection 1, 3
• Mechanical hemoclips are especially useful for actively bleeding larger vessels 1, 3
• Band ligation appears to be the most efficient procedure for both primary hemostasis and preventing recurrent bleeding 4

Endoscopic therapy is very effective and safe, with successful hemostasis achieved in all treated patients in one series 5. Approximately 30% of patients with Mallory-Weiss tears require endoscopic intervention 5.

Pharmacologic Therapy

The role of acid suppression remains somewhat controversial:

• Proton pump inhibitors have proven efficacy in peptic ulcer hemorrhage but an unestablished role in Mallory-Weiss tears; their use may be considered on a case-by-case basis to enhance clot stability 1
• High-dose PPI therapy (omeprazole 80 mg bolus followed by 40 mg IV every 8 hours for 1 day, then 40 mg orally every 12 hours for 4 days) can be administered after endoscopic therapy, though evidence is stronger for peptic ulcer disease 2
• Histamine-2 receptor antagonists lack convincing evidence for benefit in Mallory-Weiss bleeding and are not recommended 1
• Antiemetics may be logical to prevent further retching and vomiting, though evidence for efficacy is limited 4

Post-Endoscopy Management

After successful endoscopic evaluation or treatment:

• Feed patients within 24 hours if they are at low risk for rebleeding (clean base, no active bleeding) 2
• Monitor for rebleeding defined as fresh hematemesis, melena with shock, or hemoglobin reduction >20 g/L over 24 hours 1
• Address underlying causes of vomiting to prevent recurrence 1
• Discharge is appropriate for stable patients with no stigmata of recent hemorrhage after successful endoscopy 2, 1

Common Pitfalls to Avoid

• Do not assume all Mallory-Weiss tears require endoscopic therapy—most resolve spontaneously, and unnecessary procedures should be avoided 1
• Do not delay endoscopy in shocked patients (tachycardia >100 bpm, systolic <100 mmHg), as urgent assessment within hours is essential for optimal outcomes 1
• Do not underestimate mortality risk in elderly patients or those with serious comorbidities—these conditions, rather than the tear itself, drive adverse outcomes and warrant more aggressive monitoring 1
• Do not overlook non-GI causes of upper GI bleeding in patients presenting with hematemesis, as more than one-third may be bleeding from treatable non-malignant causes such as peptic ulcers or varices 2