Mallory-Weiss syndrome in children

The aim of the study was to evaluate the incidence and the etiology of Mallory-Weiss syndrome in children. The study population comprised 2720 children aged 5 months to 18 years who had undergone upper gastrointestinal endoscopy. Mallory-Weiss syndrome was diagnosed in eight (0.3%) of the examined children. Endoscopic examination in five of them revealed linear mucosal tears, mostly above and in one case also below the gastroesophageal junction. In three children a linear scar in the lower portion of the esophagus was seen. No signs of active bleeding were revealed in any of the cases. In four children, Mallory-Weiss syndrome was accompanied by gastritis and duodenitis; two of these children had Helicobacter pylori infection. The concomitant diseases were H. pylori-positive duodenal ulcer (1), bronchial asthma and gastroesophageal reflux disease (1), carbon monoxide poisoning (1). In one case Mallory-Weiss syndrome was diagnosed in early pregnancy. Mallory-Weiss syndrome should be considered, along with others, as a cause of acute upper gastrointestinal bleeding in children. There is a great variety of etiologic factors in Mallory-Weiss syndrome in children.

Mallory-Weiss syndrome: clinical features and management

OBJECTIVE

To report the clinical features, endoscopic appearance, management and outcome of patients with upper gastrointestinal bleeding due to Mallory-Weiss tear seen at our institution during the last seven years.

METHODS

A retrospective study of all patients with upper gastrointestinal bleeding seen during the last seven years was performed. Patients who were bleeding from longitudinal non-perforating tear(s) of the gastro-oesophageal mucosa were included in the study and their clinical features, endoscopic appearance management and outcome were recorded.

RESULTS

During the study period 426 patients with upper gastrointestinal bleeding were seen. Sixty-six (15.5%) of these were found to have bled or were bleeding from Mallory-Weiss tear(s). Twenty-seven (41%) patients with Mallory-Weiss tear had no antecedent nausea, retching, abdominal pain or vomiting. Two patients had portal hypertension and a solitary case bled from an iatrogenic tear induced during routine upper gastrointestinal endoscopy. Multiple bleeding episodes were seen in 12% of cases. Twenty (30%) patients needed endoscopic sclerotherapy. Haemostasis was achieved in all. Except retrosternal pain, no procedure related complications were seen.

CONCLUSIONS

Mallory-Weiss tear is a common cause of upper gastrointestinal bleeding. Nearly half of the patients have no antecedent symptoms and presented for the first time with upper gastrointestinal bleeding. Endoscopic therapy is very effective and safe in producing haemostasis in these patients.

Endoscopic ligation for non-esophageal variceal upper gastrointestinal hemorrhage

BACKGROUND

Endoscopic ligation can be used for bleeding lesions in non-fibrotic tissue; however, only small numbers of patients with non-esophageal variceal upper gastrointestinal hemorrhage have been treated in this way. To evaluate the utility of the technique, we performed the procedure to treat hemorrhage not from esophageal varices during emergency endoscopy.

PATIENTS AND METHODS

Bleeding was identified from gastric Dieulafoy's ulcers (n=4), duodenal ulcers (n=3), gastric angiodysplasia (n=2) and Mallory-Weiss tears (n=3). The bleeding points were aspirated and controlled by endoscopic ligation and complete hemostasis was achieved in all cases.

RESULTS

Although these lesions were located in difficult areas where endoscopic injection therapy and clipping sometimes fail, endoscopic ligation was performed easily and effectively without complications. Six of the patients had severe underlying disease, including acute and chronic myelogenous leukemia, liver cirrhosis and chronic renal failure; none suffered deterioration in their general condition after endoscopic ligation.

CONCLUSIONS

Our findings suggest that endoscopic ligation is an easy and effective method of treatment for patients with gastrointestinal hemorrhage not from esophageal varices, and is safe even in patients with poor general health.

[The surgical procedure in the Mallory-Weiss syndrome]

The authors dealt with treatment of 112 patients aged 27-70 years with the Mallory-Weiss syndrome. The diagnosis was confirmed by esophagogastroduodenoscopy. Diathermocoagulation was used in order to arrest bleeding. In profuse bleeding the margins of the mucosa fissures were first infiltrated with a solution of adrenaline. The Blakemore [correction of Bleikmorr] probe compression method was also used. Organ-saving operations were performed for continuing and recurrent bleedings. Two elderly patients with severe coexistent disease died. The authors consider that patients with the Mallory-Weiss syndrome must be treated by conservative methods. Operations for disruptions of the esophagus mucosa and acute blood loss will entail great risk.

[Mallory-Weiss syndrome]

Mallory-Weiss syndrome is one of the cause of upper gastrointestinal hemorrhage, which an abrupt rise in abdominal pressure due to nausea or vomiting induces a tear near the esophagogastric mucosal junction. Mallory-Weiss syndrome represents about 3-15% of all cases of upper gastrointestinal hemorrhage. Mallory-Weiss tear is mainly located on the cardia part of the stomach side and spanning across the esophagogastric mucosal junction, only in esophageal side is rarely seen. Hemorrhage frequently ceases spontaneously. When endoscopic findings reveal persistent hemorrhage, endoscopic hemostatic technique using heater probe thermocoagulation or hemoclipping is necessary. After endoscopic hemostasis, fasting and inhibitors of acid secretion (H2-receptor antagonists or proton pump inhibitors) are recommended.

[The role of endoscopy in determining the indications for the surgical treatment of the Mallory-Weiss syndrome and of bleeding acute gastroduodenal ulcers]

The frequency of acute sources of bleeding has recently increased (47%) in the general picture of gastrointestinal bleedings which makes the improvement of diagnosing "acute" sources of hemorrhage and the development of more perfect methods of nonoperative hemostasis very actual. The authors believe that "Kaprofer" used in most of patients with bleedings from acute ulcers and ruptures of the gastro-esophageal zone mucosa (95%) allows the hemorrhage to be arrested. The treatment can be continued without operative interventions. Search for new hemostatic drugs must be performed in order to obtain reliable and long-term effects of drugs with a minimum aggressive action upon the mucosa.

[Mallory-Weiss syndrome. Clinical cases and review of the literature]

Once considered rare, Mallory-Weiss syndrome is today more frequently reported due to the introduction of endoscopy which reveals this syndrome in up to 15% of hemorrhages of the upper digestive tract. The etiopathogenesis is not limited to the three factors reported by Mallory and Weiss in 1929: vomit, alcohol and hematemesis. An important role is also played by ASA and the like. This syndrome is also frequently associated with hiatus hernia in which it appears to be a complication since the lesion seems to be caused by the difference between intragastric (above all in the pocket of the hiatus hernia) and intrathoracic transmural pressure. Every increase in the pressure gradient at this level appears to cause fissuration at the cardioesophageal junction. Even endoscopy using rigid instruments and unsufflation may provoke the onset. Anamnesis and an objective examination, common to other pathologies, are not of great value to diagnosis. Radiology also contributes little, unless an arteriography is performed within the context of a highly selective angiography. Endoscopy is the prime method of diagnosis and, in addition to revealing the site and extent of hemorrhage, may be used to achieve hemostasis. Preendoscopic hemostasis currently uses a wide range of methods ranging from sclerotherapy to the injection of drugs or chemical substances, such as ethanol, adrenalin and thrombin; monopolar and bipolar electrocoagulation, thermal probe, hemoclips and Nd:YAG laser are also used. According to the majority of authors, the course of the syndrome is benign unless there are complications such as mediastinitis, pneumonia ab ingestis or hepatic insufficiency. The degree of bleeding is also decisive and the number of blood units transfused is of particular importance in determining the prognosis. The authors report a 10-year survival rate of approximately 70%.

Mallory-Weiss syndrome in a patient with hemophilia A and chronic liver disease

Eighty percent of hemophiliacs exposed to plasma products are seropositive to hepatitis B and an even higher percentage are seropositive to hepatitis C. Post-transfusion hepatitis is followed by cirrhosis in up to 25% of the cases. In the wake of portal hypertension, the development of oesophageal varices entails the risk of life-threatening hemorrhage. We report on a patient with moderate hemophilia A (factor VIII:C 4-11%) who suffered from massive hematemesis, melaena and evolving shock after excessive alcohol ingestion. The diagnosis of Mallory-Weiss syndrome and the differential diagnosis of bleeding oesophageal varices as well as prognostic consequences are discussed.

Clinical significance of Mallory-Weiss tears

OBJECTIVES

To assess course and outcome of patients with endoscopically diagnosed Mallory-Weiss tear bleeding.

SUBJECTS

Thirty-four subjects seen during a 5-yr period formed the study group.

RESULTS

Available follow-up after index bleed was 27.5 months +/- 2.7 SEM. There was no antecedent explanation for the tear, such as nausea, retching, abdominal pain, or vomiting in 12/28 (42.9%). Hematemesis on first emesis was noted in 13/26 (50%). Mean transfusion requirements were 2.6 +/- 1.0 (SEM) units of packed cells (range, 0-28), and 9/34 (26.5%) received four or more units. Two had therapeutic endoscopy and three required surgery to control bleeding. Thirty-day mortality noted four deaths, all multiorgan system failure related to the bleed. Patients who died had other endoscopic abnormalities, such as ulcers or varices, and all had an alcohol history. Two patients of 20 contacted had recurrent bleeding. One had another tear. The other had intermittent recurrent bleeding and refused care.

CONCLUSIONS

Mallory-Weiss tear bleeding may be significant and recurrent. It may cause death or require transfusion, therapeutic endoscopy, and surgery.

Mechanical gastritis as cause of upper gastrointestinal hemorrhage

Mechanical gastritis is confirmed as one of the causes of upper gastrointestinal hemorrhage, which is created directly by retching and vomiting in a patient with an esophageal hiatal hernia. Five cases of mechanical gastritis are reported in this paper. The clinical presentation of mechanical gastritis and the Mallory-Weiss syndrome may mimic each other. Upper gastrointestinal endoscopy showed the gastric mucosa to be propelled into the esophagus during nausea. This mucosa showed erosions and superficial ulcerations. The mucosa appeared 'congested' at and just below the cardia. It is suggested that the friction and compression of the gastric mucosa prolapsing through a constriction ring of the diaphragm into the hiatal hernia during retching and vomiting may cause mechanical trauma to the gastric mucosa, resulting in gastritis, erosions, and hemorrhage.

Esophageal apoplexy: case report, review, and comparison with other esophageal disorders

Esophageal injuries are potentially serious disorders requiring prompt recognition and management. In addition to the well-recognized Mallory-Weiss and Boerhaave's syndromes, there exists a condition of spontaneous intramural esophageal hemorrhage: esophageal apoplexy. A case of esophageal apoplexy is presented as well as an evaluation of clinical presentations based on a collected review of the 66 cases previously reported. In addition, esophageal apoplexy is contrasted with the Mallory-Weiss and Boerhaave's syndromes, focusing on distinguishing attributes of utility to the emergency practitioner.

[The pathogenesis, clinical picture and diagnosis of the Mallory-Weiss syndrome]

The authors consider that predisposing factors in the development of the Mallory-Weiss syndrome include restriction of mobility of the mucous and submucous layers of the cardia in relation to one another, uncoordinated and oppositely directed contractions of differently oriented muscle layers of the lower third of the esophagus and cardial portion of the stomach, incompetence of the cardial closing apparatus. Rupture of the wall of the stomach and duodenum is associated with an immediate dramatic change of the intragastric pressure. The endoscopic method of examination is thought to be the leading one in diagnosing the Mallory-Weiss syndrome.

The current role of endoscopy in Mallory-Weiss syndrome

We have carried out a retrospective review of 61 patients with Mallory-Weiss syndrome, 9 of whom underwent hemostatic injection treatment. At emergency endoscopy, 3 patients (5%) were actively bleeding and 6 (10%) had stigmata of recent hemorrhage. Fifty-two patients had a lesion of the cardia which was the suspected source of bleeding in 33 cases (54%). In the remaining 19 cases (31%) this site was not considered responsible because other sites of bleeding were present in the upper gastrointestinal tract. The 9 patients with active bleeding or stigmata of recent hemorrhage underwent injection treatment and the other 52 patients were treated with H2 antagonists. The low rebleed rate and the zero mortality recorded in this series indicate that endoscopy is the optimum method for diagnosis and treatment of patients with Mallory-Weiss syndrome.

[Mallory-Weiss syndrome in children]

The article analyzes an experience with treatment of 18 children with the Mallory-Weiss syndrome. Six children were operated upon, one of them died. Questions of pathogenesis of this syndrome in children practice are considered on the basis of anatomo-physiological properties of the child's organism. Attention was paid to the diagnostic and medical role of endoscopy. The tactics of treatment of this disease is recommended based on reference of the blood loss degree and findings of the endoscopic examination.

[Mallory-Weiss syndrome in acute poisoning with non-caustic substances]

The authors presented the results of diagnostic and therapeutic esophagogastroduodenoscopy in the Mallory-Weiss syndrome observed in patients with acute ++non-caustic poisoning. Altogether 47 patients were investigated for suspected gastrointestinal bleeding. The Mallory-Weiss syndrome was detected in 20 (42.5%) patients. Therapeutic endoscopic intervention was performed in 5 cases of this syndrome to stop bleeding.

[Mallory-Weiss syndrome. Surgical treatment after sclerotherapy. Presentation of a case and review of the literature]

We herein report a case of a male patient aged 23, with acute upper gastrointestinal hemorrhage, secondary to ingestion of acetyl salicylic acid. Endoscopy showed a linear laceration in the esophagus-gastric union. Based on endoscopic findings the diagnosis of Mallory-Weiss Syndrome was established. Surgical treatment was required, after sclerotherapy; we reviewed the literature for presenting a general panorama of this pathology.