Upper Gastrointestinal Bleeding: Boerhaave vs Mallory-Weiss Syndrome

Upper gastrointestinal (GI) bleeding is a common and sometimes life-threatening medical condition that often presents with hematemesis (vomiting blood) or melena (black tarry stools). Among its causes, Boerhaave syndrome and Mallory Weiss syndrome are two important conditions that result from esophageal injury, usually after episodes of forceful vomiting.

✅ What Happens During Vomiting?

When a person vomits forcefully, the pressure inside the stomach and esophagus rises sharply. If that pressure becomes excessive, it may lead to tearing of the esophageal lining.

This injury can range from:

• superficial mucosal tears (Mallory-Weiss)
  to

• full-thickness rupture (Boerhaave)

Mallory-Weiss Syndrome

📌 Definition

Mallory-Weiss syndrome is caused by longitudinal mucosal tears at the gastroesophageal junction, typically after repeated vomiting or retching.

🧠 Key Mechanism

✔ Partial tear
✔ Limited to the mucosa and submucosa
✔ Usually not life-threatening, but can cause bleeding

Common Triggers

• Excessive alcohol use

• Eating disorders (bulimia)

• Severe coughing

• Pregnancy-related vomiting

• Seizure-related vomiting

Clinical Presentation

• Painful hematemesis after vomiting

• Bright red or coffee-ground blood

• Mild epigastric discomfort

Treatment

Most cases resolve without intervention, but if bleeding persists:
✅ IV fluids
✅ Proton pump inhibitors (PPIs)
✅ Endoscopic hemostasis (clipping, cautery)
✅ Rarely requires surgery

Boerhaave Syndrome

📌 Definition

Boerhaave syndrome is a spontaneous full-thickness rupture of the esophagus caused by sudden increase in intraesophageal pressure—most often due to forceful vomiting.

🧠 Key Mechanism

❗ Complete tear through all layers
❗ Leads to leakage of esophageal contents into the mediastinum
❗ Causes mediastinitis, sepsis, and shock if untreated

Classic Trigger

• Forceful vomiting after heavy meals or alcohol

Clinical Presentation

This is a medical emergency. Typical findings include:

• Severe chest pain after vomiting

• Subcutaneous emphysema (air under skin)

• Tachycardia, fever

• Dyspnea (difficulty breathing)

• Signs of septic shock in severe cases

✨ Classic Triad (Mackler triad):

1. Vomiting

2. Chest pain

3. Subcutaneous emphysema

Treatment

✅ Immediate stabilization
✅ Broad-spectrum antibiotics
✅ CT esophagography (diagnosis)
✅ Surgical repair or endoscopic stenting
✅ ICU monitoring

📊 Comparison Table: Boerhaave vs Mallory-Weiss

Feature	Mallory-Weiss Syndrome	Boerhaave Syndrome
Depth of tear	Mucosa / submucosa only	Full-thickness rupture
Location	Gastroesophageal junction	Distal esophagus
Main problem	Bleeding	Perforation + mediastinitis
Symptoms	Hematemesis, mild pain	Severe chest pain, sepsis
Severity	Often self-limited	Life-threatening emergency
Treatment	Supportive ± endoscopy	Surgery + antibiotics

Key Takeaway

✅ Mallory-Weiss = mucosal tear → bleeding
🚨 Boerhaave = full rupture → infection + sepsis

If a patient has vomiting followed by chest pain and systemic toxicity, always think Boerhaave syndrome and act fast.

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