Mallory-Weiss syndrome. A study of 224 patients

Manner of death determination in a case of gastric mucosal tears

Gastric tears are rarely described in the forensic pathological literature, although they can lead to a fatal acute exsanguination. Such lesions can arise from several conditions leading to an increased intragastric pressure, such as Mallory Weiss syndrome, cardiopulmonary resuscitation, acute barotrauma and operative procedures, showing peculiar morphological features. We present a case of a 32-year-old drug addicted white woman found dead in a pool of blood in the house of her drug dealer, after taking a dose of intravenous heroin. At autopsy, abundant bloody gastric content and multiple and long gastric tears, extending from the cardias and fundus regions to the gastric corpus were observed; one of them involved the subserous region, resulting in a gastric wall rupture. The victim had no history of recent vomiting and of gastro-intestinal pathologies. Drugs and ethanol levels detected in the specimens of the victim were not consistent with lethal concentrations, thus the death was attributed to acute exsanguination. After reviewing the literature, it turned out that morphological aspects of the gastric tears, such as number, size and topographical distribution, observed at autopsy were atypical compared to those of typical gastric lacerations.

Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms

Gastrointestinal (GI) bleeding is a common potentially life-threatening medical condition frequently requiring multidisciplinary collaboration to reach the proper diagnosis and guide management. GI bleeding can be overt (eg, visible hemorrhage such as hematemesis, hematochezia, or melena) or occult (eg, positive fecal occult blood test or iron deficiency anemia). Upper GI bleeding, which originates proximal to the ligament of Treitz, is more common than lower GI bleeding, which arises distal to the ligament of Treitz. Small bowel bleeding accounts for 5-10% of GI bleeding cases commonly manifesting as obscure GI bleeding, where the source remains unknown after complete GI tract endoscopic and imaging evaluation. CT can aid in identifying the location and cause of bleeding and is an important complementary tool to endoscopy, nuclear medicine, and angiography in evaluating patients with GI bleeding. For radiologists, interpreting CT scans in patients with GI bleeding can be challenging owing to the large number of images and the diverse potential causes of bleeding. The purpose of this pictorial review by the Society of Abdominal Radiology GI Bleeding Disease-Focused Panel is to provide a practical resource for radiologists interpreting GI bleeding CT studies that reviews the proper GI bleeding terminology, the most common causes of GI bleeding, key patient history and risk factors, the optimal CT imaging technique, and guidelines for case interpretation and illustrates many common causes of GI bleeding. A CT reporting template is included to help generate radiology reports that can add value to patient care. An invited commentary by Al Hawary is available online. Online supplemental material is available for this article. ^©RSNA, 2021.

Risk factors for Mallory-Weiss Tear during endoscopic submucosal dissection of superficial esophageal neoplasms

BACKGROUND

Adverse events during endoscopic submucosal dissection (ESD) of superficial esophageal neoplasms, such as perforation and bleeding, have been well-documented. However, the Mallory-Weiss Tear (MWT) during esophageal ESD remains under investigation.

AIM

To investigate the incidence and risk factors of the MWT during esophageal ESD.

METHODS

From June 2014 to July 2017, patients with superficial esophageal neoplasms who received ESD in our institution were retrospectively analyzed. The clinicopathological characteristics of the patients were collected. Patients were divided into an MWT group and non-MWT group based on whether MWT occurred during ESD. The incidence of MWTs was determined, and the risk factors for MWT were then further explored.

RESULTS

A total of 337 patients with 373 lesions treated by ESD were analyzed. Twenty patients developed MWTs during ESD (5.4%). Multivariate analysis identified that female sex (OR = 5.36, 95%CI: 1.47-19.50, P = 0.011) and procedure time longer than 88.5 min (OR = 3.953, 95%CI: 1.497-10.417, P = 0.005) were independent risk factors for an MWT during ESD. The cutoff value of the procedure time for an MWT was 88.5 min (sensitivity, 65.0%; specificity, 70.8%). Seven of the MWT patients received endoscopic hemostasis. All patients recovered satisfactorily without surgery for the laceration.

CONCLUSION

The incidence of MWTs during esophageal ESD was much higher than expected. Although most cases have a benign course, fatal conditions may occur. We recommend inspection of the stomach during and after the ESD procedure for timely management in cases of bleeding MWTs or even perforation outside of the procedure region.

Mallory-Weiss tear as a rare complication during esophageal endoscopic submucosal dissection

There are no previous reports of Mallory-Weiss tears occurring as complications during esophageal endoscopic submucosal dissection (ESD). We present 3 cases of Mallory-Weiss tears occurring during treatment of superficial squamous cell neoplasms through ESD. Carbon dioxide was used for air insufflation, and the patient was adequately sedated without retching or struggling during the operation. No significant bleeding from the lesion was observed during ESD; however, active bleeding caused by the Mallory-Weiss tear was identified endoscopically. Bleeding was controlled by closure of the tear with metal clips or repeated flushing with adrenaline saline. Hemorrhage did not recur until completion of the operation. Therefore, during the operation, it is necessary to maintain adequate depth of anesthesia and reduce the operation time, and also reduce air and water injections, to avoid occurrence of such complications.

Management of non-variceal upper gastrointestinal bleeding: where are we in 2018?

Acute upper gastrointestinal bleeding (AUGIB) is one of the most common medical emergencies in the UK. Despite advancement in technology the management of AUGIB remains a challenge. The clinical community recognise the need for improvement in the treatment of these patients. AUGIB has a significant impact on resources. Endoscopic therapy is the gold standard treatment. The mortality in AUGIB is rarely related to the presenting bleed but significantly associated with concurrent comorbidities. The cost of blood transfusion in the management of patients with AUGIB is significant and misuse of blood products has been documented nationally. Risk stratification tools such as Glasgow-Blatchford Score, Rockall Score and the AIMS65 score have allowed clinicians to triage patients appropriately in order to deliver endoscopic therapy within a suitable time frame. Endoscopic therapeutic modalities such as epinephrine injection, heat thermocoagulation and mechanical clips have had a positive impact on patient's management. However, in order to continue to improve patient's outcomes, further developments are needed.

Effective endoscopic treatment of Mallory-Weiss syndrome using Glasgow-Blatchford score and Forrest classification

OBJECTIVES

There is limited data on whether scoring systems can be used to predict clinical outcomes in patients with upper gastrointestinal bleeding due to Mallory-Weiss syndrome (MWS). We aimed to evaluate whether the Glasgow-Blatchford score (GBS) could be effective in predicting clinical outcomes of bleeding MWS and to investigate the predictive ability of the Forrest classification for rebleeding and assess the effective endoscopic modalities for bleeding control in MWS.

METHODS

From January 2004 to December 2012 168 patients were diagnosed with MWS in the Asan Medical Center Emergency Department. We analyzed their clinical outcomes, including endoscopic treatment, transfusion and admission as well as the rates of rebleeding and mortality using GBS and the Forrest classification, retrospectively.

RESULTS

Endoscopic treatment was applied to patients. The GBS was significantly higher in patients treated with endoscopic therapy than in the conservative treatment group (6.8 ± 3.7 vs 5.1 ± 4.7, P = 0.011). In patients with a GBS of >6 the rates of endoscopic treatment and rebleeding and the need for transfusion and admission were significantly higher (all P < 0.05). The Forrest classification was able to predict recurrent bleeding (area under the receiver operating characteristic curve 0.723, 95% confidence interval 0.609-0.836, P = 0.025). Hemoclip-based therapy and band ligation achieved higher success rates than did injection therapy alone in preventing rebleeding (96.4%, 88.9% and 71.4%, P = 0.013).

CONCLUSION

In MWS, GBS might be useful for predicting clinical outcomes and the Forrest classification in predicting recurrent bleeding.

Old technique revisited with surgical innovation: complicated Mallory-Weiss tear with bleeding gastric ulcer exclusion

Mallory–Weiss tears (MWTs) rarely require surgical intervention. A 60-year-old female presented with massive hematemesis secondary to MWT and gastric ulceration. After failure of endoscopic management, an operative approach was embarked on, with a direct surgical hemostasis of the Mallory–Weiss tear and exclusion of the gastric ulcer. This exclusion strategy may be applicable for other patients with uncontrolled upper gastrointestinal bleeding in whom a simple repair would be difficult.

Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis

AIM: To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy’s lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis.

METHODS: Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: “alcoholic liver disease”, “alcoholic hepatitis”,“ alcoholic cirrhosis”, “cirrhosis”, “liver disease”, “upper gastrointestinal bleeding”, “non-variceal upper gastrointestinal bleeding”, “PUD”, ‘‘DL’’, ‘‘Mallory-Weiss tear”, and “MWS’’.

RESULTS: While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population.

CONCLUSION: Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS.

Circumferential distribution and location of Mallory-Weiss tears: recent trends

BACKGROUND AND STUDY AIMS

Mallory-Weiss tears (MWTs) are not only a common cause of acute nonvariceal gastrointestinal bleeding but also an iatrogenic adverse event related to endoscopic procedures. However, changes in the clinical characteristics and endoscopic features of MWTs over the past decade have not been reported. The aim of this study was to investigate recent trends in the etiology and endoscopic features of MWTs.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of patients with a diagnosis of MWT at our university hospital between August 2003 and September 2013. The information regarding etiology, clinical parameters, endoscopic findings, therapeutic interventions, and outcome was reviewed.

RESULTS

A total of 190 patients with MWTs were evaluated. More than half (n = 100) of the cases occurred during endoscopic procedures; cases related to alcohol consumption were less frequent (n = 13). MWTs were most frequently located in the lesser curvature of the stomach and right lateral wall (2 - to 4-o'clock position) of the esophagus, irrespective of the cause. The condition of more than 90 % of the patients (n = 179) was improved by conservative or endoscopic treatment, whereas 11 patients (5.8 %) required blood transfusion. Risk factors for blood transfusion were a longer laceration (odds ratio [OR] 2.3) and a location extending from the esophagus to the stomach (OR 5.3).

CONCLUSIONS

MWTs were frequently found on the right lateral wall (2 - to 4-o'clock position) of the esophagus aligned with the lesser curvature of the stomach, irrespective of etiology. Longer lacerations extending from the esophagus to the gastric cardia were associated with an elevated risk for bleeding and requirement for blood transfusion.

Asymptomatic Free Air Caused by Mallory-Weiss Tears during Endoscopy

An 80-year-old woman was referred to our hospital for the treatment of advanced gastric cancer which extended from the antrum to the bulbus of the duodenum. Although the patient did not struggle or retch during endoscopy, multiple mucosal lacerations were observed in the proximal stomach by Mallory-Weiss tears. No evidence of perforation was identified at the sites. The day after endoscopy, computed tomography revealed free air close to the gastric cardia, but the patient did not complain of any symptoms; she was able to consume a normal diet and did not require any treatment.

Mallory-Weiss Tear during Esophagogastroduodenoscopy

Mallory-Weiss tears (MWTs) are mucosal lacerations caused by forceful retching and are typically located at the gastroesophageal junction. Reported cases of MWT with serious complications seen in esophagogastroduodenoscopy are limited. We report MWT in an 81-year-old woman who presented with gastric perforation by esophagogastroduodenoscopy. We discuss and indicate that hiatal hernia, atrophic gastritis and old age may be associated with the gastric perforation in comparison to typical tears occurring at the gastroesophageal junction.

Characterization of the syndrome of UGI bleeding from a Mallory-Weiss tear associated with transesophageal echocardiography

AIM

To quantitatively describe the syndrome of Mallory-Weiss tears associated (MWa) with antecedent transesophageal echocardiography (TEE) as a distinct syndrome.

METHODS

Cases of MWa were identified by comprehensive, computerized literature search via PubMed and review of textbooks and monographs on TEE and gastroenterology. Statistical comparison of 17 identified MWa cases versus previously published series of 73 cases of Mallory-Weiss tears unassociated with TEE (MWu) was performed. A new illustrative case is also currently reported.

RESULTS

Comparison between these two groups revealed the following: MWa patients were significantly older (67.1 vs. 52.6 years, p = .0002, assuming equal variance), likely due to MWa patients having preexisting cardiovascular disease for which the TEE was indicated. The two groups had similar sex distributions (60 vs. 76% male, p = .32). MWa patients were significantly, more frequently anticoagulated at the time of bleeding (90.9 vs. 9.6%, p < .00001, OR = 94.3, 95%-OR CI: 9.56-2293), likely because of anticoagulation for underlying cardiac disease for which TEE was indicated. MWa patients tended to more frequently rebleed and more frequently require endoscopic therapy (both parameters: 4/17 vs. 8/73, p = .23) and tended to more frequently require surgery or angiography to control bleeding (3/17 vs. 3/73, p = .08). MWa patients had significantly higher mortality (23.5 vs. 2.7%, p = .01, OR = 10.9, 95%-OR CI 1.48-97.8), likely because of their older age, concomitant heart disease, and administered anticoagulation. A new case of MWa is reported with notable features that extend the clinical spectrum of this syndrome: (1) tear associated with hiatal hernia, (2) presentation with severe, fatal UGI bleeding, and (3) no anticoagulation during bleeding episode.

CONCLUSIONS

Patients with MWa represent a distinct clinical subset from patients with MWu, with significantly older mean age, more frequent concomitant anticoagulation, and higher mortality. They also tend to have more severe bleeding. These characteristics are important in clinically managing this syndrome.

Management of upper gastrointestinal bleeding emergencies: evidence-based medicine and practical considerations

Acute upper gastrointestinal (GI) bleeding remains one of the most common encounters in emergency medicine. The increased use of non-steroid anti-inflammatory drugs by the general population and the increased prescription of anti-platelet agents and anti-coagulants after cardiovascular interventions and for prevention of cerebral vascular accidents may have aggravated the situation. Significant progress has been made in the past decade or so in the non-surgical management of acute upper GI bleeding emergencies. This article will review the current standard treatment of the most common upper GI bleeding emergencies in adults as supported by evidence-based medicine with practical considerations from the authors' own practice experience.

Upper gastrointestinal bleeding

Upper gastrointestinal (GI) bleeding remains a commonly encountered diagnosis for acute care surgeons. Initial stabilization and resuscitation of patients is imperative. Stable patients can have initiation of medical therapy and localization of the bleeding, whereas persistently unstable patients require emergent endoscopic or operative intervention. Minimally invasive techniques have surpassed surgery as the treatment of choice for most upper GI bleeding.

Non-variceal gastrointestinal bleeding in patients with liver cirrhosis: a review

BACKGROUND

Non-variceal gastrointestinal (NVGI) bleeding in cirrhosis may be associated with life-threatening complications similar to variceal bleeding.

AIM

To review NVGI bleeding in cirrhosis.

METHODS

MEDLINE, Scopus, and ISI Web of Knowledge were searched, using the textwords "portal hypertensive gastropathy," "gastric vascular ectasia," "peptic ulcer," "Dieulafoy's," "Mallory-Weiss syndrome," "portal hypertensive enteropathy," "portal hypertensive colopathy," "hemorrhoids," and "cirrhosis."

RESULTS

Portal hypertensive gastropathy (PHG) and gastric vascular ectasia (GVE) are gastric lesions that most commonly present as chronic anemia; acute upper GI (UGI) bleeding is a rare manifestation. Management of PHG-related bleeding is mainly pharmacological, whereas endoscopic intervention is favored in GVE-related bleeding. Shunt therapies or more invasive techniques are restricted in refractory cases. Despite its high incidence in cirrhotic patients, peptic ulcer accounts for a relatively small proportion of UGI bleeding in this patient population. However, in contrary to general population, the pathogenetic role of Helicobacter pylori infection remains questionable. Finally, other causes of UGI bleeding include Dieulafoy's lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids. However, the vast majority of studies are case reports and, therefore, the incidence, diagnosis, and risk of bleeding remain undefined. Endoscopic interventions, shunting procedures, and surgical techniques have been described in this setting.

CONCLUSIONS

The data on NVGI bleeding in liver cirrhosis are surprisingly scanty. Large, multicenter epidemiological studies are needed to better assess prevalence and incidence and, most importantly, randomized studies should be performed to evaluate the success rates of therapeutic algorithms.

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.

Differential diagnosis of upper gastrointestinal bleeding proximal to the ligament of Trietz

Upper gastrointestinal bleeding (UGIB) is an important medical problem for patients and the medical system. The causes of UGIB are varied and their accurate identification guides appropriate management. The major cause of UGIB is peptic ulcer disease, for which Helicobacter pylori and nonsteroidal antiinflammatory drug use are major risk factors. Lesser causes include Dieulafoy lesion, gastric antral vascular ectasia, hemobilia, aortoenteric fistulas, and upper gastrointestinal tumors. Awareness of causes and management of UGIB should allow physicians to treat their patients more effectively.

The use of endoclips in the treatment of nonvariceal gastrointestinal bleeding

Acute nonvariceal gastrointestinal bleeding is the most common emergency managed by endoscopists and the endoscopic therapy has generally been recommended as the first-line treatment. Traditionally, endoscopic treatment included injections of epinephrine and sclerosing solutions or the use of thermocoagulation. In the last decade with the introduction of hemoclips and band ligators, we have witnessed a significant improvement in the clinical outcome of nonvariceal gastrointestinal bleeding. Endoclipping is a safe and effective technique that contributes to hemostasis of bleeding lesions of the gastrointestinal tract.

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 band ligation and endoscopic hemoclip placement for patients with Mallory-Weiss syndrome and active bleeding

AIM: To compare the hemostatic efficacy and safety of two mechanical endoscopic methods: endoscopic band ligation (EBL) and endoscopic hemoclip placement (EHP) in patients with actively bleeding Mallory-Weiss syndrome (MWS).

METHODS: A prospective randomized study to compare the efficacy and safety of EHP with EBL was performed from January 2002 to August 2005. Forty-one patients with active bleeding from MWS were treated with EHP (n = 21) or EBL (n = 20).

RESULTS: There were no significant differences between groups with respect to clinical and endoscopic characteristics. The mean number of hemoclips applied was 3.2 ± 1.5 and the mean number of bands applied was 1.2 ± 0.4. Primary hemostasis was achieved in all patients. Recurrent bleeding was observed in one patient from the EHP group and two from the EBL group. Patients with recurrent bleeding were treated by the same modality as at randomization and secondary hemostasis was achieved in all. There were no significant differences between the two groups in total transfusion amount or duration of hospital stay. No complications or bleeding-related death resulted.

CONCLUSION: EHP and EBL are equally effective and safe for the management of active bleeding in patients with Mallory-Weiss syndrome, even in those with shock or comorbid diseases.

Risk stratification in upper gastrointestinal bleeding

Acute upper gastrointestinal (UGI) bleeding is a common clinical problem that accounts for a large number of hospitalizations and results in substantial health care expenditures. Risk stratification after UGI hemorrhage involves the use of clinical and endoscopic parameters to predict the likelihood of rebleeding and death. This information can guide management decisions, such as the necessity of hospital admission, the application of endoscopic hemostatic therapy, and the length of inpatient stay. This concise review examines the current literature on risk stratification in UGI hemorrhage and attempts to integrate evidence-based data into the clinical decision-making process.

Acute necrotizing esophagitis: role of nonsteroidal anti-inflammatory drugs

BACKGROUND

Acute necrotizing esophagitis (ANE) is a rarely described entity that is thought to be a cause of upper gastrointestinal (UGI) bleeding, The present study examined the incidence of ANE among patients with UGI bleeding, as well as the clinical features of ANE, and the coexisting illnesses and medication histories of ANE patients.

METHODS

A retrospective analysis of clinical and endoscopic findings and the clinical course in 16 patients with ANE was carried out over a 3-year period.

RESULTS

We observed 16 patients (6%) of ANE in 239 patients with UGI bleeding during the 3-year period. The average age of the patients was 62.5 years. The lesions predominantly affected the lower third of the esophagus, and hiatal hernia was the most common (63%) coexisting endoscopic finding. All patients had coexisting disease. Fifty percent of patients with ANE (eight patients) had taken nonsteroidal anti-inflammatory drugs (NSAIDs). ANE also occurred in four patients with diabetic ketoacidosis. Supportive therapy, including parenteral nutrition and administration of a proton pump inhibitor, was effective.

CONCLUSIONS

ANE is more common than has been previously reported, and it should be included in the differential diagnosis of UGI bleeding. ANE could be characterized as an "acute esophageal mucosal lesion," particularly in aged patients with hiatal hernia and among those who consume NSAIDs.

A prospective, randomized trial of endoscopic band ligation vs. epinephrine injection for actively bleeding Mallory-Weiss syndrome

BACKGROUND

Effective hemostatic treatment is mandatory for patients with actively bleeding Mallory-Weiss syndrome. This study evaluated the respective efficacy and the safety of endoscopic band ligation and endoscopic epinephrine injection in Mallory-Weiss syndrome.

METHODS

Thirty-four consecutive patients with actively bleeding Mallory-Weiss syndrome were prospectively enrolled and were randomly assigned to undergo endoscopic band ligation or endoscopic injections of a 1:10,000 solution of epinephrine. Demographic characteristics, endoscopic variables, and outcome parameters, including rates of hemostasis and recurrent bleeding, were analyzed.

RESULTS

The number of elastic bands applied was one or two; the mean volume of epinephrine injected was 18.0 mL: 95% CI[16.8, 19.2]. There was no significant difference between the groups with respect to age, gender, alcohol ingestion, presenting symptoms, Hb level, shock, comorbid diseases, coagulopathy, tear location, blood transfusion, or duration of hospitalization. Primary hemostasis was achieved in all 17 patients in the band ligation group and in 16 of 17 patients (94.1%) in the epinephrine injection group. There was no recurrence of bleeding or major complication in either group.

CONCLUSIONS

In this small study, no difference was detected in the efficacy or the safety of band ligation vs. epinephrine injection for the treatment of actively bleeding Mallory-Weiss syndrome.

Therapeutic Alternatives for the Mallory-Weiss Tear

The Mallory-Weiss tear (MWT) is a frequent cause of upper gastrointestinal bleeding. It has been diagnosed more frequently since endoscopy was introduced. Once the diagnosis has been made, several treatment options are available. The treatment modality chosen depends on the type and location of the lesion, the patient's comorbid conditions, the availability of the different therapeutic modalities, and the experience of the endoscopist with each of these different modalities. In general, if the MWT is not actively bleeding at the time of endoscopy, no further treatment is needed owing to a low risk of rebleeding, unless a visible vessel is present. In the presence of a visible vessel or an actively bleeding vessel, then we recommend the use of any of the endoscopic treatment modalities discussed later in this article depending on the patient's condition and clinical scenario. Our review of the literature suggests that multipolar electric coagulation (MPEC) is the treatment modality with better evidence-based support for safety and bleeding control. MPEC has been associated only with very few complications. It should be avoided when esophageal varices are suspected because it may precipitate and aggravate bleeding. In such instances, either polidocanol injection or endoscopic band ligation of the tear is recommended, which is emerging as a safe and effective treatment modality even in patients without varices. In addition, epinephrine injection is an effective first-line modality. However, it should be avoided in patients with history of coronary artery disease owing to the potential for systemic absorption. Endoscopic hemoclipping (EH) is another useful treatment option and is emerging as a first-line modality. However, it is not widely available in all endoscopy emergency units. If it is available, it is a great alternative. Finally, if bleeding continues or recurs despite endoscopic therapy, the patient should be referred for surgical treatment. However, if the patient is not a surgical candidate, then radiologic hemostasis with selective vasopressin or Gelfoam embolization represents a viable treatment alternative that may be used depending on availability of a specialized interventional radiologist.

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.

Management of gastrointestinal haemorrhage

A variety of endoscopic haemostatic techniques have enabled major advances in the management of not only bleeding peptic ulcers and bleeding varices, but also in a variety of bleeding lesions in the small intestine and in the colon. Indeed, the development and widespread implementation of endoscopic haemostasis has been one of the most important developments in clinical gastroenterology in the past two decades. An increasingly ageing cohort of patients with multiple co-morbidity are being treated and therefore improving the outcome of gastrointestinal bleeding continues to pose major challenges.

Management principles of gastrointestinal bleeding

There is now a multitude of technologic and pharmacologic options available to clinicians caring for patients with gastrointestinal (GI) bleeding; however, drugs and technology are no substitute for understanding and properly executing the basic management principles of GI bleeding. This article focuses on the most common causes of GI bleeding and emphasizes the importance of the primary care provider's role in the management of these patients. Also, by answering questions we are commonly asked as gastroenterology consultants, we hope to provide insight into current diagnostic and therapeutic options and the most appropriate use of these options.

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.

Efficacy of endoscopic isotonic saline-epinephrine injection for the management of active Mallory-Weiss tears

Therapeutic endoscopy with isotonic saline-epinephrine (ISE) injection is a convenient and widely used procedure for hemostasis in upper gastrointestinal bleeding. We retrospectively evaluated 36 patients (from January 1996 to April 1999) who had been diagnosed with recent or active bleeding due to Mallory-Weiss tears in emergency endoscopic examination. The endoscopic hemostatic method with ISE injection was performed in 15 of 36 patients. The other 21 patients received conservative treatment with hemodynamic support. Patient's clinical data, laboratory data, transfusion requirements, endoscopic findings, and length of hospital stays were evaluated. Initial hemoglobin was significantly lower in the ISE group than the conservative treatment group (9.74 +/- 2.86 g/dL vs. 12.57 +/- 2.80 g/dL, respectively; p < 0.01). Mean transfusion requirements were significantly higher in the ISE group than the conservative treatment group (7.26 +/- 8.78 units vs. 2.85 +/- 6.21 units, respectively; p < 0.1). Patients in the ISE group were supposed to be having a more severe bleeding episode. Most patients achieved initial hemostasis in the ISE group and the conservative treatment group (93% and 95%, respectively). The rebleeding rate was also similar in both groups (1 in 15 in the ISE group and I in 21 in the conservative treatment group). There was no significant difference in length of hospital stay and rebleeding between these two groups (3.47 +/- 1.92 days vs. 2.47 +/- 1.47 days, respectively: p = 0.89). The endoscopic ISE injection is an inexpensive, simple, convenient therapeutic method and it can achieve initial hemostasis for active Mallory-Weiss tears.

Mallory-Weiss Syndrome: Possible Link to Water Immersion and Subsequent Air Flight

Mallory-Weiss Syndrome (MWS) lesions account for up to 15 per cent of upper gastrointestinal bleeding episodes. Typically these lesions present as a consequence of vomiting that is often associated with alcoholism. Recently other conditions such as pregnancy, migraine, hiatal hernia, gastric ulcer, biliary disease, and various medications have been associated with MWS. We report on a 32-year-old male who developed a MSW lesion after a prolonged period of swimming followed by an extended commercial airplane flight. The hemodynamic changes associated with swimming (increased central distribution of blood volume) and the pressure changes in commercial aircraft (a reduction of 0.3 atmospheres of pressure) are discussed. We conclude that the combination of these factors contributed to the development of a MWS lesion and gastrointestinal bleeding in this patient. We recommend that both air travel and athletic activities be considered as possible contributing factors in the evaluation of the cause of new-onset gastrointestinal bleeding.

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.

Acute gastrointestinal bleeding in the intensive care unit. The intensivist's perspective

Gastrointestinal (GI) hemorrhage is a common and potentially lethal medical emergency that is a common cause for intensive care unit admission. The intensivist plays an important role as a member of the medical team managing the patient with GI bleeding who is at high risk because of severe bleeding, comorbidity, or the presence of endoscopic stigmata of recent hemorrhage. This article presents the intensivist's approach to GI hemorrhage in initial patient assessment, triage, resuscitation, specialist consultation, diagnostic evaluation, and medical therapy. This article focuses on types of GI bleeding of particular concern to the intensivist, including esophageal variceal bleeding, stress-related GI bleeding, and GI bleeding associated with myocardial infarcation.

Surgical management of gastrointestinal bleeding

Severe gastrointestinal bleeding has historically been a clinical problem primarily under the purview of the general surgeon. Diagnostic advances made as the result of newer technologies, such as fiberoptic and video endoscopy, selective visceral arteriography, and nuclear scintigraphy, have permitted more accurate and targeted operations. More importantly, they have led to safe, effective nonoperative therapeutic interventions that have obviated the need for surgery in many patients. Today, most gastrointestinal bleeding episodes are initially managed by endoscopic or angiographic control measures. Such interventions are often definitive in obtaining hemostasis. Even temporary cessation or attenuation of massive bleeding in an unstable patient permits a safer, more controlled operative procedure by allowing an adequate period of preoperative resuscitation. Despite the less frequent need for surgical intervention, traditional operative approaches, such as suture ligation, lesion or organ excision, vagotomy, portasystemic anastomosis, and devascularization procedures, continue to be life-saving in many instances. The proliferation of laparoscopic surgery has fostered the application of minimally invasive techniques to highly selected patients with gastrointestinal bleeding. Intraoperative endoscopy has greatly facilitated the accuracy of laparoscopic surgery by endoscopic localization of bleeding lesions requiring excision. It is anticipated that the evolving technologies pertinent to the diagnosis and management of gastrointestinal bleeding will continue to promote collaboration and cooperation between gastroenterologists, radiologists, and surgeons.

The spectrum of spontaneous and iatrogenic esophageal injury: perforations, Mallory-Weiss tears, and hematomas

Esophageal perforations, Mallory-Weiss tears, and esophageal hematoma involve traumatic injury to the esophagus. These can be iatrogenic, in particular due to esophageal instrumentation, but can also occur spontaneously. The remarkable increase in diagnostic and therapeutic endoscopy as well as esophageal surgery has made instrumentation the most common cause of esophageal perforation. In many instances, spontaneous perforations are associated with retching and vomiting, which causes a sudden increase in intraesophageal pressure. A high index of suspicion leading to rapid diagnosis and appropriate therapy are needed to optimize clinical outcomes. This article focuses on esophageal perforations, Mallory-Weiss tears, and esophageal hematomas, with emphasis on etiology, pathogenesis, clinical presentation, diagnosis, management, and prevention.

The spectrum of diaphragmatic hernia

Diaphragmatic hernias are among the most common abnormalities of the gastrointestinal tract. Those with significant paraesophageal features may require surgical intervention to prevent potentially lethal complications. By contrast, 90% of patients with sliding hiatal hernias respond favorably to behavior modification and antisecretory drug therapy.

Upper gastrointestinal tract bleeding

Upper GI bleeding is a serious and common emergency. Most upper GI bleeding will stop spontaneously but determining which patients will continue to bleed or rebleed is very difficult in the ED. Resuscitation and stabilization are the primary goals of the emergency physician. Hemorrhage control with pharmacotherapy or balloon tamponade may be necessary until urgent or emergent consultation with a gastroenterologist or surgeon is obtained. Early detection and treatment of H. pylori and the development of safer NSAIDs should alter the future of upper GI bleeding dramatically.

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.

Laparoscopic oversewing of a bleeding Mallory-Weiss tear under endoscopic guidance

Continuous bleeding from a Mallory-Weiss tear required laparoscopic surgery to halt the bleeding. The oversewing of the laceration at the esophagogastric junction was readily performed under video control with endoscopic guidance and the bleeding ceased. To stop bleeding from such a tear, we prefer to use this modern approach.

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.