Mallory-Weiss syndrome. Review of 69 cases

Mallory-Weiss syndrome: clinical and endoscopic characteristics

BACKGROUND

Mallory-Weiss syndrome is defined by upper gastrointestinal bleeding from vomiting-induced mucosal lacerations at the esophago-gastric junction. This study was purposed to investigate the incidence, location, clinical manifestation, diagnosis and effectiveness of treatment (including endoscopic treatment and conservative medical treatment) of Mallory-Weiss syndrome in China.

METHODS

All patients who received emergency upper gastrointestinal endoscopy due to Mallory-Weiss syndrome from September 2007 to August 2011 at gastrointestinal endoscopy center of Renmin Hospital of Wuhan University were included in this study. The clinical presentation, medical history, location and characteristics of Mallory-Weiss syndrome methods and effectiveness of therapy of patients with Mallory-Weiss syndrome were retrospectively analyzed by chart reviews. Long-term follow-up data were collected at outpatient clinics or telephone interviews.

RESULTS

Sixteen patients were diagnosed with Mallory-Weiss syndrome, which account for 3.08% of 519 patients with acute non-variceal upper gastrointestinal bleeding. Common comorbidities were found in one patient with hepatic cirrhosis. Conservative medical treatment, local injection, hemoclipping, or multipolar electrocoagulation produced primary hemostasis in 87.5% (14/16) of patients.

CONCLUSION

Mallory-Weiss syndrome is uncommon in China in comparison with reported experience in the west when the same group of patients is selected. Different approaches to treatment are to be recommended depending on whether or not active hemorrhage is present.

Mallory-Weiss tear diagnosed in the immediate postpartum period: a case report

BACKGROUND

Mallory-Weiss tears occur rarely during pregnancy, labour and delivery, and the puerperium, despite the increased frequency of retching and vomiting.

CASE

We describe a Mallory-Weiss syndrome diagnosed during the immediate postpartum period in a 34-year-old primigravida. The syndrome initially manifested as lower gastrointestinal bleeding and melena.

CONCLUSION

If unrecognized, this complication may lead to life-threatening internal bleeding. It is important to look for an occult bleeding source with such a presentation, and prompt intervention is essential.

Endoscopic hemostasis with metallic hemoclips for iatrogenic Mallory-Weiss tear caused by endoscopic examination

AIM

Applied endoscopic techniques including mucosal resection, sclerotherapy and endoscopic retrograde cholangiopancreatography (ERCP) have been advanced and iatrogenic complications including Mallory-Weiss tear (MWT) occasionally occur in daily endoscopic procedures. The present study aimed to examine the advantages of clipping for MWT complications that occur during endoscopic examination.

METHODS

Over 10 years, we experienced 47 patients with bleeding caused by MWT. Metallic hemoclips were applied for 38 patients for hemostasis. These patients were categorized into two groups: 18 patients in group A whose bleeding tear occurred during endoscopic examination in an iatrogenic condition, and 20 patients in group B visited the emergency unit due to other etiology of MWT.

RESULTS

The background characteristics, including length of tears, were not different between the two groups. Initial hemostasis was 100% in groups A and B. Rebleeding was 0/18 (0%) in group A and 1/20 (5 %) in group B. Number of patients who received blood transfusion was significantly higher in group B (group A: 0/18, group B: 4/20). Hemoglobin level before hemostasis was 12.5 g/dL in group A which was not different to that in group B, 10.9 g/dL.

CONCLUSION

Application of hemoclips was effective for bleeding MWT during endoscopic procedures, which warranted prophylactic application of hemoclips on MWT during endoscopic examination.

Endoscopic hemoclip placement and epinephrine injection for Mallory-Weiss syndrome with active bleeding

BACKGROUND

Mallory-Weiss syndrome with active bleeding requires effective hemostasis. This is an investigation of the respective efficacy and safety of endoscopic hemoclip placement and endoscopic epinephrine injection in Mallory-Weiss syndrome.

METHODS

Thirty-five patients with Mallory-Weiss syndrome with spurting vessels or oozing in a university hospital were enrolled prospectively and randomly assigned to endoscopic hemoclip placement (18 patients) or endoscopic epinephrine injection (17 patients) performed by 4 endoscopists with similar clinical experiences. Demographic characteristics, endoscopic variables, and outcome parameters as well as rates of hemostasis and recurrent bleeding were analyzed.

RESULTS

The mean (SD) number of hemoclips applied was 2.5 (1.2) and the mean volume of injection was 7.9 (4.3) mL. Primary hemostasis was achieved in all 35 patients. In each group there was 1 case of recurrent bleeding. Secondary hemostasis was achieved by repeating the same procedures as at randomization in both cases. There were no significant differences in age, gender, prior ingestion of alcohol, presenting symptoms, hemoglobin level, shock, comorbid diseases, bleeding stigmata, tear location, blood transfusion, or hospitalization between the groups. There were no procedure-related complications in either group; surgery was not required in any patient. For both groups, there were no second episodes of recurrent bleeding, procedure-related complication, or need of operation.

CONCLUSION

Endoscopic hemoclip placement and endoscopic epinephrine injection are equally effective and safe for the management of active bleeding in Mallory-Weiss syndrome, even in patients with shock or comorbid diseases.

Mallory-Weiss tear: predisposing factors and predictors of a complicated course

OBJECTIVES

Little has been published regarding predictors of a complicated course after Mallory-Weiss tear (MWT). The aims of this study were to identify risk factors for a Mallory-Weiss tear and factors predictive of a complicated course.

METHODS

At our university hospital, we searched a computerized endoscopy database. At our Veterans Affairs hospital we manually searched printed endoscopy reports. Proposed risk factors for MWT were: history of alcohol use, recent alcohol binge, nonbloody initial emesis, anticoagulation, other coagulopathy, nonsteroidal anti-inflammatory use, and hiatal hernia. Proposed predictors of a complicated course were: age, hematemesis, melena, hematochezia, visible vessel, adherent clot, active bleeding, multiple tears, other pathology at endoscopy, admission Hct, hypotension or orthostatic changes, and coagulopathy. A complicated course was defined on the basis of >6 U of blood transfused, rebleeding, angiography, surgery, or death. Predictors of a complicated course were evaluated using the Mann-Whitney U test or Fisher exact test.

RESULTS

A total of 73 cases were reviewed. The most common risk factor was alcohol use, which was found in 44% of cases. In all, 23% of patients had no risk factors. Of the patients, 17 (23%) had a complicated course. Patients with a complicated course had a lower admission Hct (p = 0.009) and active bleeding at initial endoscopy (p = 0.013).

CONCLUSION

The predictive value of active bleeding supports early endoscopy for stratification and intervention.

Endoscopic hemoclipping for upper GI bleeding due to Mallory-Weiss syndrome

BACKGROUND

Endoscopic hemoclipping is known to be highly effective as hemostatic treatment for upper gastrointestinal bleeding. However, the efficacy and safety of hemoclipping for Mallory-Weiss syndrome (MWS) have not been reported. Thus, the aim of the present study was to assess prospectively the usefulness of endoscopic hemoclipping for MWS bleeding.

METHODS

This study was conducted from January 1994 to August 1999. Hemoclipping was performed when active bleeding (spurting, streaming or oozing), visible vessels or fresh adhesive clots were found on endoscopic examination. Patients who did not have any of these findings were conservatively treated. Follow-up endoscopy was performed within 24 hours, after 5 days and between 1 and 2 months after the procedure.

RESULTS

MWS was diagnosed in a total of 58 patients during the study. Hemoclipping was performed in 26 patients and was technically successful in all cases. The average number of hemoclips used was 2.8 +/- 1.6 (range 1 to 8). The number of hemoclips required for hemostasis depended on the nature of the bleeding. No complications, recurrent bleeding, or deaths resulted. Follow-up endoscopy showed no evidence of hemoclip-induced tissue injury and no impairment of Mallory-Weiss tears.

CONCLUSION

Endoscopic hemoclipping provided an effective and safe modality for obtaining hemostasis when bleeding is due to MWS.

Mallory-Weiss syndrome with severe bleeding: treatment by endoscopic ligation

There is no consensus as to the best treatment for Mallory-Weiss tears with severe bleeding. Endoscopic ligation is an inexpensive, readily available, and easily learned technique, in contrast to conventional thermocoagulation or hemoclipping. To evaluate the utility of endoscopic ligation, we performed this technique during emergency endoscopy to treat severe bleeding from Mallory-Weiss tears in four patients in our hospital with continuous active bleeding from Mallory-Weiss tears. The patients were all male with an average age of 40.5 years. Symptoms associated with increased intra-abdominal pressure, including retching and vomiting were reported by all patients. The bleeding points were aspirated and controlled by endoscopic ligation, and complete hemostasis was achieved in all cases. We conclude that endoscopic ligation is easy to perform and may provide an alternative treatment for severe bleeding from Mallory-Weiss tears.

Esophagogastric hematoma mimicking a malignant neoplasm: clinical manifestations, diagnosis, and treatment

Esophagogastric hematoma is a rare condition occurring spontaneously or after esophageal instrumentation. In this report, we describe a patient with acute dysphagia in whom a lower esophageal mass was detected radiographically. Upper endoscopy revealed an esophageal mass that extended from the mid-esophagus to the gastroesophageal junction and was associated with a malignant-appearing ulcerated mass (5 to 6 cm) in the cardia. Gastric cancer with esophageal extension was the presumptive diagnosis. Computed tomography showed that the esophageal mass had a density similar to blood, a finding suggesting the presence of an esophageal hematoma. Biopsy specimens of the ulcer revealed acute inflammation but no malignant involvement. The patient was treated conservatively, and the initial symptoms resolved. Esophagogastric hematomas can mimic a neoplasm; thus, establishing the correct diagnosis is important because this condition has a favorable prognosis, and only conservative treatment is needed.

Nonvariceal upper gastrointestinal bleeding

The approach to nonvariceal UGI bleeding has been reviewed. Therapeutic endoscopy has been shown to be superior to medical therapy in patients with an actively bleeding ulcer and those at high risk of rebleeding. Of endoscopic therapies available to the GI endoscopist, multipolar electrocoagulation, heater probe, and injection therapy are comparable in efficacy and safety.

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.

Sudden postoperative death caused by unheralded Mallory Weiss tears

Mallory Weiss tears are a common cause of upper gastrointestinal bleeding, typically reported as following repeated vomiting after an alcoholic binge. This association may have been overemphasised, and these lesions could be caused by a wide range of spontaneous and iatrogenic events. A case of sudden postoperative death caused by massive haematemesis, unheralded by any evidence of vomiting or retching, as a result of Mallory Weiss tears is reported.

Platelet satellitism and alpha granule proteins

Blood smears from a patient with severe generalised arteriopathy and an occluded synthetic femoropopliteal graft showed the phenomenon of EDTA dependent adherence of platelets to neutrophils (platelet satellitism). Immunoenzymatic staining with a monoclonal antibody to thrombospondin showed that adherence to neutrophils exclusively involved platelets that stained strongly positive for thrombospondin, while negative or weakly positive platelets showed no tendency to adhere. There was no increase in platelet surface immunoglobulins. This suggests a possible role for thrombospondin or some other cytoadhesive platelet alpha granule protein in mediating the adherence of platelets to neutrophils in cases of satellitism.

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. Experience in a community hospital

The Mallory-Weiss syndrome is characterized by repeated bouts of retching and/or vomiting followed by the sudden onset of hematemesis or melena. Bleeding arises from linear, nonperforating mucosal lacerations at the cardia, cardioesophageal junction, distal esophagus, or a combination of these sites. Hiatal hernia is often a coexisting finding. Severity of hemorrhage can vary from mild to severe (100 to 2,000 ml). The clinical course is usually benign. The diagnosis can be suspected from the history and confirmed by upper gastrointestinal endoscopy. In the majority of patients, medical management controls the bleeding. About 10% to 20% of unselected patients require surgical intervention. With the proper, prompt use of fiberoptic endoscopy in the diagnosis of upper gastrointestinal hemorrhage has come an increase in the number of cases of Mallory-Weiss syndrome being identified. This is true even in community hospitals. The result has been a decrease in surgical intervention and overall mortality.

Mallory-Weiss syndrome. A study of 224 patients

With the increasing early use of endoscopy, Mallory-Weiss syndrome has been found to be the cause of upper gastrointestinal bleeding in 224 of 2,175 (10.3 percent) patients studied. Since Mallory-Weiss syndrome is a self-limiting disease in more than 90 percent of patients, conservative treatment, including multiple transfusion, electrocoagulation, and compression by a Sengstaken-Blakemore tube in descending order of use, is the treatment of choice, especially in the medically debilitated patient. The cirrhotic patient poses special difficulty and generally has a poor outcome no matter what the treatment. Prolapse of the stomach into the esophagus may be an etiologic factor in a small subgroup of patients.