Mallory-Weiss Syndrome To Boerhaave Syndrome – A Spectrum

Mallory-Weiss syndrome is characterized by the presence of longitudinal superficial mucosal lacerations/tear occur primarily at the gastroesophageal junction, may extend proximally to involve the distal esophagus or distally to involve the stomach.

Boerhaave syndrome ( spontaneous esophageal rupture ) is rare, though frequently fatal, the event caused by a sudden increase in pressure intraluminal distal esophageal pressure leading to complete transmural tear generally associated with pneumomediastinum and mediastinal collections.

However, sometimes, full-thickness rupture of the esophagus may occur superimposed on prior superficial tears (Mallory-Weiss syndrome) due to further triggering events ( heavy alcohol ingestion) causing forcefully projection of gastric contents to give rise to a complete transmural extension of the tear.

Here is a case of a 40-year-old alcoholic male presenting 3rd time in a period of 6 months with hematemesis, chest pain, tenderness over the thoracic region after heavy alcohol ingestion.

CT lower thorax and abdomen performed on a dual slice CT scanner demonstrates a linearly oriented transmural hypoattenuating tear is noted at GE junction level extends from mucosal surface to a well-contained para esophageal collection. Distal esophagus and GE junction are circumferentially edematous with high and low attenuation intramural areas. No evidence of pneumomediastinum or extraesophageal mediastinal collections.

CONCLUSION:

This case was a lesson to us that :

1. distal esophageal tears, may not always constitute a distinct entity ( either Mallory Weiss or Boerhaave syndrome)   and it could be a part of a spectrum of diseases, and

2. A superficial esophageal tear may subsequently evolve into a full-thickness rupture following further triggering events.

MALLORY-WEISS SYNDROME TO BOERHAAVE SYNDROME SPECTRUM

Aetiology & risk factors:

It occurs due to repeated projection of gastric contents against the lower esophagus, causing mucosal and submucosal tears with involvement of the venous plexus. Frequently associated with heavy alcohol ingestion. 

Other risk factors include hiatal hernia, hyperemesis gravidarum, and gastroesophageal reflux disease.

Pathology:

A superficial longitudinal laceration at distal esophagus / GE junction without transmural perforation (Mallory-Weiss syndrome). A deep laceration at distal esophagus / GE junction with complete transmural perforation leading to pneumomediastinum and mediastinitis (Boerhaave Syndrome).

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