Mallory-Weiss syndrome occurring as a complication of endoscopy

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.

Risk Factors for an Iatrogenic Mallory-Weiss Tear Requiring Bleeding Control during a Screening Upper Endoscopy

Background and Aim. In some cases of iatrogenic Mallory-Weiss tears (MWTs), hemostasis is needed due to severe mucosal tearing with bleeding. Therefore, we aimed to evaluate the risk factors for severe iatrogenic MWTs and the methods of endoscopic bleeding control. Materials and Methods. Between January 2008 and December 2012, 426,085 cases of screening upper endoscopy were performed at the Asan Medical Center. We retrospectively analyzed the risk factors for severe iatrogenic MWTs requiring an endoscopic procedure and the treatment modalities of bleeding control. Results. Iatrogenic MWTs occurred in 546 cases (0.13%) of screening upper endoscopy in 539 patients. Bleeding control due to severe bleeding was applied in 71 cases (13.0%), and rebleeding after initial bleeding control occurred in 1 case. Multivariate analysis showed that old age, a history of distal gastrectomy, and a less-experienced endoscopist (fewer than 2,237.5 endoscopic procedures at the time of the MWT) were associated with severe iatrogenic MWTs requiring an endoscopic procedure. Among 71 cases requiring bleeding control, a hemoclip was used in 81.7% (58 cases). Conclusions. Screening endoscopy procedures should be carefully performed when patients are in their old age and have a history of distal gastrectomy, particularly if the endoscopist is less experienced.

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.

Use of propofol versus propofol combined with fentanyl during painless gastroscopy in elderly patients

AIM: To assess the advantages and disadvantages of two intravenous anesthesia strategies used for painless gastroscopy in elderly patients.

METHODS: Sixty elderly patients who underwent gastroscopy at our hospital from May 2008 to February 2011 were included. The patients were randomly and equally divided into two groups (A and B) and underwent treatment with either intravenous propofol or propofol combined with fentanyl. The OAAS criteria were adopted, and a score < 2 was used as the critical value. Those who did not reach the critical value were additionally given propofol 10-30 mg. The time required for reaching the critical value, recovery time, and orientation recovery time were compared. Using the time point at 20 min prior to anesthesia as the basic point, the heart rate (HR), blood pressure (BP), respiratory rate (RR), and SPO₂ at 5 min after anesthesia were compared.

RESULTS: All the 60 patients felt asleep and completed gastroscopy. 46 cases waked up 1-5 min after gastroscopy, and 14 cases became completely conscious in 15 min. Both the time of reaching the critical value and analepsia in group A were significantly lower than those in group B (19.5 min ± 2.6 min vs 14.9 min ± 3.1 min, 17.5 min ± 2.2 min vs 11.1 min ± 1.7 min, both P < 0.01). The orientation recovery time did not significantly differed between the two groups (P > 0.05). HR, BP, RR, and SPO₂ were all decreased to some extent in both groups in the first 5 min. The decreasing amplitude of HR in group A was significantly higher than that in group B (-9.9 time/min ± 5.1 time/min vs -13.2 time/min ± 4.7 time/min, P < 0.05), but the decreasing amplitude of systolic pressure was significantly lower in group A than in group B (P < 0.01). The decreasing amplitude of RR and SPO₂ showed no significant difference between the two groups (both P > 0.05).

CONCLUSION: Intravenous propofol combined with fentanyl is an effective and safe anesthesia method in painless endoscopy in elderly patients, with less stimulation of pharyngeal reflex and less effect on the circulatory and respiratory systems.

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.

The role of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal disorders

Esophagogastroduodenoscopy has revolutionized the clinical management of upper gastrointestinal diseases. Millions of EGDs are performed annually in the United States for many indications, such as gastrointestinal bleeding, abdominal pain, dysphagia, or surveillance of premalignant lesions. Esophagogastroduodenoscopy is very safe, with a low risk of serious complications such as perforation, cardiopulmonary arrest, or aspiration pneumonia. It is a highly sensitive and specific diagnostic test, especially when combined with endoscopic biopsy. Esophagogastroduodenoscopy is increasingly being used therapeutically to avoid surgery. New endoscopic technology such as endosonography, endoscopic sewing, and the endoscopic videocapsule will undoubtedly extend the frontiers and increase the indications for endoscopy.

Management of gastrointestinal bleeding induced by gastrointestinal endoscopy

Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.

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.

Critical appraisal of transesophageal echocardiography: limitations, pitfalls, and complications

Because transesophageal echocardiography is invasive, it has the potential for serious complications. Limitations occur because of the restricted transducer mobility within transducers for special situations. Pitfalls (potential erroneous diagnoses resulting from misinterpretation of normal and abnormal anatomy) are prevalent with this new technology. This report critically reviews transesophageal echocardiography and discusses and illustrates commonly encountered limitations, pitfalls, and complications.

Mallory-Weiss syndrome secondary to cis-platinum chemotherapy: an unusual complication

The Mallory-Weiss syndrome is a relatively infrequent cause of digestive tract bleeding and most cases have been described in alcoholics. Nonoperative management is frequently successful. We present here a case of sudden onset of wretching and vomiting after IV infusion of cis-platinum for recurrent carcinoma of the uterine cervix in which the patient had profuse hematemesis secondary to three posterior gastroesophageal tears requiring operative intervention after failure of nonsurgical management. This is an unusual complication of antineoplastic chemotherapy and its prevention is emphasize in this paper.

Complications of fiberoptic endoscopy

This review summarizes the complications of fiberoptic peroral endoscopy, endoscopic retrograde cholangiopancreatography and colonoscopy gleaned from reports of extensive endoscopic surveys. Unique individual experiences are also included. Means whereby complications can be prevented or remedied are noted.