The prevalence and risk factors for Mallory-Weiss syndrome: a systematic review and meta-analysis

INTRODUCTION

Mallory-Weiss syndrome characterized by a laceration in mucous membrane at gastro esophageal junction, is a disease of gastro intestinal tract.¹ The condition was first described by Mallory and Weiss in 1929.² They observed the condition in alcoholic patients involving vomiting and persistent retching.³ According to the research, of all GIT bleeding cases up to 15% account for MWS.⁴ It can affect individuals of any age and race, but individuals with middle age are more affected with the condition.⁵ Furthermore, it has been found that men are more susceptible compared to women with 2:4.1 ratio.⁶

There are not always symptoms associated with MWS except minor bleeding. The most common symptoms in some cases are vomiting, retching, bloody stools and abdominal pain.⁷ Usually the blood appearing in vomiting is of dark red color sometimes black in the form of clots. The blood appearing in the stool is usually of black color like tar.⁸ The prevalence of MWS varies and range from 1-15% in various populations. For example, Hiroyuki et al found the prevalence of 9.1% and corral found it to be 3.2%. ^9,10

There are number of causes for MWS such as prolonged vomiting, gastritis, hiatal hernia, trauma, hiccups, coughing, and convulsions.¹¹ A number of studies have been conducted associating various risk factors with the development of MWS. For example, Sato et al investigating the association of esophageal hiatus hernia with MWS found that the incidence of Hiatus hernia is higher in MWS patients compared to the controls. The study concluded that HH is the predisposing factor for MWS development.¹² In contrast, Corral et al studying the relationship between HH and MWS found more HH incidence in control compared to the MWS group and concluded that HH is not associated with MWS.

Other studies have investigated different risk factors for MWS association. For example, a study by Dona et al found alcohol consumption and complicated course of disease associated with MWS syndrome.¹³ Similarly, Craft et al found out strong association of hiccups with the development of MWS.¹⁴

Although a number of studies have been conducted in past to determine the prevalence of MWS and investigate the association of different risk factors for MWS development. There is a variation and sometimes conflicting results.

Furthermore, there is no meta-analysis on the topic. So, we conducted this systematic review and meta-analysis to determine the overall effect size for the prevalence of MWS and to see how strongly different risk factors such as Hiatus hernia, alcohol consumption, GERD etc. are associated with the development of th MWS.

METHODS

Study selection

The study was conducted according to the preferred reporting for systematic reviews and meta-analysis (PRISMA) guidelines. The studies included in the SR were case-control, cross sectional, prospective and retrospective. Any population, age group, gender group, and race were included. The studies were excluded if the studies were case reports, not in English language.

Duration

This systematic review and meta-analysis were conducted from 10 March, 2021 to 12 April, 2021.

Literature search strategy

We did the literature search in online databases such as PubMed Medline, Embase, Cochrane library, Google scholar and Science direct. The key words used for the search were “Mallory Weiss syndrome” “Gastroesophageal Laceration-Hemorrhage” “Mallory-Weiss” Laceration Mallory-Weiss Tear” “Hiatus hernia” “Alcohol” “GERD” “Prevalence” Risk factor.”

The initial article identification was performed based on title and abstract reading by two separate investigators. Later, full articles were reviewed for potential exclusion. The articles which did not fall in inclusion criteria were excluded and remaining full text articles were stored for data extraction.

Data extraction

Two separate investigators extracted the data from studies. The data extracted were study related such as author’s information, date of publication, country of origin. The patient’s related data extracted were condition, age, gender, race and other information available. Finally, the data required for MA such as prevalence and OR was extracted. 2 separate investigators performed all steps and if any conflict was found, it was resolved with discussion.

Quality assessment of studies

The studies included in this SR and MA was assessed for their quality using new castle Ottawa scare (NOS). According to the scale the score >7 was considered as high-quality studies, the score 5-7 was medium quality studies and the score <5 was labeled as low-quality studies.

Statistical analysis

The standard forest plots were used to see the overall effect sizes of various measures. For prevalence, we used mean %ages and their 95% CIs will use to draw forest plots. For risk factors association, we used OR and their 95% CIs. To determine heterogeneity, I² test and the Cochrane’s Q statistic was used. I² value of <50% will be considered low heterogeneity, I² value of 50-75% considered as moderate and I² value >50% considered as high heterogeneity. Finally, funnel plots were used to determine publication bias.

RESULTS

The literature search initially yielded 540 articles. Based on the Titles and abstract screening, 440 articles were excluded. Full texts of the remaining 100 articles were reviewed which left with 30 articles. After duplication removal 21 articles (15-35) were left which were included in the final analysis. The literature search procedure is summarized in Figure 1.

Study and patient characteristics

21 studies were included in this SR and MA discussing prevalence and risk factors associated with MWS. 15 of the studies had provided prevalence of MWS. The risk factors studied were Hiatus Hernia, Alcohol, and Hiccups etc. The majority of studies were about Hiatus Hernia as risk factor for MWS (12 studies). 5 studies discussed Alcohol as risk factor for MWS and the remaining 4 studies were about Hiccups as risk factor for MWS. Regarding the study designs of the included studies, mostly (11) were case control study, 4 retrospective, 4 prospective, and 2 cross sectionals.

Geographic distribution of studies was as follows: 37% were from Asia, 33% from the United States, 14% from Europe, 10% from the Middle East, and 6% from South America. Further study and patient characteristics are summarized in. Total number of subjects in all 21 studies was 621. 300 were patients and 321 were control subjects.

There were 12 studies related to hiatus hernia as risk factor. The total numbers of patients were 232, among which 28% were women, and 72% were men. Mostly the patients were White Europeans and the mean age calculated was 42.32 years. In Alcohol related studies, there were 131 patients. Mostly white Europeans with the mean age of 39.85. Finally Hiccups related studies have 92 subjects all chines and European origin and the mean age was 32.32.

With respect to the study quality, 13 scored >7 at NOS scale, thus considered high quality, 3 were medium quality (scored 5-7) and the remaining 5 studies were of low quality (NOS score<5).

Meta-analysis of prevalence

There were 20 studies which provided the data for prevalence. Based on our analysis the pooled prevalence was 15.46% with 95% CI of 13.63-17.29. The lowest prevalence was found to be 7 and the highest was 45. We found the high heterogeneity between studies with I²>75%. Meta-analysis is depicted in Figure 2.

Meta-analysis of hiatus hernia as risk factor for MWS

There were 12 studies about the hiatus hernia as risk factor for MWS. The pooled effect size was found to be OR 1.96 with 95% CI of 1.96 (1.73-2.22). 30% of the studies were significant for non-association and 70% were significant for association. The overall effect size showed that HH is a significantly associated with the development of MWS (Figure 3).

Meta-analysis of alcohol as risk factor for MWS

There were 5 studies about the alcohol as risk factor for MWS. The pooled effect size was found to be OR 0.81 with 95% CI of 1.96 (0.63-1.05). 60 of the studies were significant for non-association and 70% were significant for association. The overall effect size showed that alcohol is not a significantly associated with the development of MWS (Figure 4).

Meta-analysis of hiccups as risk factor for MWS

There were 5 studies about the hiccups as risk factor for MWS. The pooled effect size was found to be OR 1.04 with 95% CI of 1.96 (0.78-1.39). 50% of the studies were significant for non-association and 50% were significant for association. The overall effect size showed that Hiccups is significantly associated with the development of MWS (Figure 5).

DISCUSSION

Mallory-Weiss syndrome is a gastro esophageal disease with varied prevalence reporting and the number of risk factors associated. This is a systematic review and meta-analysis of the prevalence of MWS and the associated risk factors. The first SR and MA on the topic have combined 21 studies and more than 600 subjects.

Our study has found the overall prevalence of 15.46%. The studies in the past have reported varied prevalence in a range of races from 7% to 45%.^36,37 The analysis further revealed that the subjects were of middle age and men were more compared to women. This is in line with the previous studies where it has been found that mostly men of middle age are affected with MWS.^38,39 Furthermore, it was also discovered that subjects of European descent were mostly affected.⁴⁰

Studies in that past have shown association with the number of factors for the development of MWS. We considered factors as hiatus hernia, Alcohol, and hiccups as association for MWS. Our analysis has shown that hiatus hernia is significantly associated with development of MWS. The studies in the past have conflicting conclusions. Some have considered hiatus hernia as a strong predicting factor for MWS while other have not considered it as a strong risk factor for MWS development.^41,42 There can be the number of reasons for this conflicting result and one of the reasons is the poor randomization and selection of subjects.⁴³ Another important risk factor discussed in this analysis was Alcohol. Studies in the past have shown that individuals diagnosed with MWS were mostly binge alcoholics so Alcohol was considered as important associating factor.⁴⁴ Our analysis finds very week association of alcohol with MWS development. An emerging risk factor being discussed in the literature was hiccups. Scholars found that people visiting hospitals with complication and symptoms of MWS were having continuous hiccups.⁴⁵ Our analysis also revealed that hiccups are associated with the development of MWS.

Like most of other studies our studies also have some limitations. First, there is a significant number of cross-sectional studies involved for conducting meta-analysis. The evidence presented by cross-sectional studies is of poorer quality compared to that presented by case-control studies. Besides, the studies were heterogeneous. Although the studies considered here had a number of confounding variables such as gender, age, and ethnicity, we did not perform a subgroup analysis based on these variables, which can affect the results. Finally, the studies had a publication bias as well.

CONCLUSION

MWS is a complication of gastro esophageal tract with a number of associated factors. The prevalence of MWS is not extensive in individuals with GIT tract complications. Hiatus hernia is strongly associated with the development of MWS. Alcohol is not a strong predictor for MWS development. An emerging risk factor showing strong association was Hiccups. There is a need of new studies with controlled conditions to properly predict risk factors.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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