Mallory-Weiss syndrome is characterized by acute upper gastrointestinal bleeding caused by mucous membrane lacerations at the gastroesophageal junction; lacerations may also extend above and/or below the junction. These lacerations are often caused by forceful vomiting in patients with gastric mucosal injury, usually related to heavy alcohol use. Patients typically present with a history of epigastric pain and hematemesis. Patients with severe bleeding may be hemodynamically unstable and, therefore, immediate hemodynamic support (e.g., IV fluid resuscitation and/or blood transfusion) may be necessary. EGD is used in both the diagnosis of Mallory-Weiss syndrome and its treatment, as it may involve simultaneous hemostasis. If EGD is unsuccessful, angiography may be considered; surgery is rarely required. Pharmacological treatment (e.g., antiemetic therapy, acid suppression) should be initiated in all patients with Mallory-Weiss syndrome; further treatment is often not required in patients without active bleeding.
- Mechanism: a sudden and severe rise in the esophageal intraluminal pressure results in tearing of the esophageal mucous membrane, as well as the submucosal arteries and veins
- Severe vomiting
- Blunt abdominal trauma
- Strained defecation
- Predisposing conditions
Suspect Mallory-Weiss syndrome in patients with upper GI bleeding and a history of precipitating factors or predisposing conditions; see “Etiology.”
- Follow a .
- Confirm the diagnosis.
Blood loss may initially be concealed because of the large volume of the GI tract.
Initial studies 
- CBC: may reveal anemia and/or thrombocytopenia
- Coagulation studies: may reveal coagulopathy (see also “Laboratory findings in bleeding disorders”)
- BMP: may show ↑ BUN:creatinine ratio
- Pretransfusion testing: blood typing and crossmatching
- Cardiac enzymes and bedside ECG: to rule out acute coronary syndrome
- Should be performed in all patients to confirm the diagnosis
- The need for urgent evaluation will depend on the severity of the bleeding; see “ .”
- Typical findings
There are no specific guidelines for the management of Mallory-Weiss syndrome; recommendations are based on guidelines for the management of. 
Start , potentially including:
- and correction of
- Empiric medical therapy for GI bleeding
- Start pharmacological therapy: to control precipitating factors and predisposing conditions (e.g., nausea and/or vomiting)
Evaluate the need for interventional therapy.
- In patients without active bleeding, noninterventional management is often sufficient.
- Consult specialists early (e.g., gastroenterology, interventional radiology )
- Treat the underlying condition: e.g., counseling on alcohol use disorder , treatment of
The use of large volumes of IV fluid during resuscitation in patients with ongoing bleeding increases the risk of dilutional coagulopathy, which can worsen the hemorrhage. Consider blood products early.
Pharmacological treatment 
The goal is to promote mucosal recovery.
- Antiemetic therapy (e.g., promethazine ): Initiate in patients with nausea, retching, and/or vomiting.
IV PPI therapy: e.g., esomeprazole or high-dose esomeprazole (off label) 
- Consider prior to EGD as part of .
- Consider continuation for 72 hours after endoscopy in patients at high risk for rebleeding.
- Oral PPI therapy (e.g., omeprazole or pantoprazole )
- IV PPI therapy: e.g., esomeprazole or high-dose esomeprazole (off label) 
- : recommended for all patients who take anticoagulants
Initiation of pharmacological therapy should not delay endoscopy.
Endoscopic treatment 
- Indication: first-line treatment for actively bleeding Mallory-Weiss tears
- Techniques 
Angiographic treatment 
Surgical treatment 
- Indication: only considered if EGD and angiographic treatment are unsuccessful and bleeding is ongoing
- Technique: surgical ligation of bleeding vessels
- ABCDE survey
- IV access
- Immediate hemodynamic support
- Acid suppression with IV PPI therapy
- Anticoagulant reversal in patients taking anticoagulants
- Antiemetic therapy for patients with nausea and/or vomiting
- Initial studies
- Gastroenterology consult for EGD
- Interventional radiology consult for angiography (if EGD is unsuccessful or unavailable)
- General surgery consult (if there is still active bleeding after EGD and angiography)
- Serial CBC; monitoring for signs of bleeding
- Continuous pulse oximetry, frequent blood pressure measurement
- ICU admission for hemodynamically unstable patients
- Alcohol cessation counseling (if applicable)