Vomiting can exert pressure on the esophagus, leading to injury. While uncommon, tears in the esophageal lining or wall are possible. Understanding these potential injuries, their signs, and how they are managed is important. This article offers clear details on esophageal tears related to vomiting.
Types of Esophageal Tears
Esophageal tears resulting from vomiting fall into two categories: Mallory-Weiss tears and Boerhaave syndrome. Mallory-Weiss tears involve longitudinal lacerations that affect the inner lining of the esophagus, the mucosa, and sometimes the layer beneath it, the submucosa. These tears typically occur at the junction where the esophagus meets the stomach, the gastroesophageal junction. Most Mallory-Weiss tears are considered less severe and often heal without extensive intervention.
In contrast, Boerhaave syndrome represents a complete, full-thickness rupture of the esophageal wall. This condition is a severe medical emergency because the rupture allows the contents of the esophagus, including food particles and digestive fluids, to leak into the chest cavity. Such leakage can lead to serious complications like infection and inflammation within the mediastinum, the space between the lungs. The tear in Boerhaave syndrome most commonly occurs in the lower part of the esophagus. While less common than Mallory-Weiss tears, Boerhaave syndrome is more life-threatening.
Identifying the Symptoms
Recognizing symptoms of an esophageal tear is important for prompt medical attention. For Mallory-Weiss tears, the most common symptom is blood in vomit, known as hematemesis. This blood can appear bright red or resemble coffee grounds. Some individuals may also notice black, tar-like stools, known as melena. Other symptoms might include nausea, lightheadedness, or upper abdominal pain, particularly after forceful vomiting or retching.
Boerhaave syndrome presents with severe symptoms due to the full-thickness rupture. The most prominent symptom is sudden, intense chest pain, which can radiate to the back or shoulder. This pain often worsens with swallowing. Patients may also experience abdominal pain, shortness of breath, a rapid heart rate, and fever. A distinct sign, though not always present, is subcutaneous emphysema, where air from the ruptured esophagus becomes trapped under the skin. The combination of vomiting, chest pain, and subcutaneous emphysema is known as Mackler’s triad, an indicator of Boerhaave syndrome.
Factors Increasing Risk
Several factors increase the likelihood of an esophageal tear from vomiting. The primary cause for both Mallory-Weiss tears and Boerhaave syndrome is a sudden, forceful increase in pressure within the abdomen and esophagus. This often occurs during episodes of severe or persistent vomiting and retching. Conditions that induce forceful vomiting, like excessive alcohol consumption, bulimia, cyclic vomiting syndrome, or severe morning sickness (hyperemesis gravidarum), are risk factors. Chemotherapy side effects can also lead to prolonged vomiting, increasing risk.
Underlying conditions affecting the esophagus can predispose an individual to these tears. A hiatal hernia, where part of the stomach pushes through the diaphragm, is often present in individuals with Mallory-Weiss tears and can heighten vulnerability. Inflammation of the esophageal lining, known as esophagitis, can weaken the tissue. Similarly, pre-existing esophageal strictures, which are narrowings, can impede the flow of contents and increase internal pressure during vomiting, contributing to tear risk.
Medical Care and Recovery
Diagnosis of esophageal tears varies by suspected type. For Mallory-Weiss tears, an upper endoscopy is the standard diagnostic tool. This procedure involves inserting a flexible tube with a camera through the mouth to visualize the esophagus and stomach, identifying the laceration and any active bleeding. For Boerhaave syndrome, imaging studies such as computed tomography (CT) scans with oral contrast confirm the diagnosis. These scans can reveal air or fluid leakage into the chest cavity, characteristic of a full-thickness rupture.
Treatment strategies vary based on the tear’s severity and type. Most Mallory-Weiss tears are managed conservatively, as the bleeding often stops spontaneously within 48 to 72 hours. This conservative approach may involve anti-nausea medications and proton pump inhibitors to reduce stomach acid and promote healing. If bleeding persists, endoscopic interventions can be performed during the initial endoscopy, such as applying clips, injecting medications to stop bleeding, or using heat (cautery) to seal the blood vessel.
Boerhaave syndrome requires immediate intervention due to its life-threatening nature. Treatment typically involves surgical repair of the esophageal rupture, often through a thoracotomy (an incision in the chest), to close the tear and drain leaked contents from the chest cavity. Broad-spectrum antibiotics are administered to prevent or treat infection. In some cases, endoscopic stents may be placed to seal the perforation. Early diagnosis and prompt treatment are important for improved outcomes and survival rates, as delays increase the risk of complications and mortality.