Severe Mallory-Weiss tear after endoscopy treated by endoscopic band ligation

Ideal strategy for nonvariceal upper gastrointestinal bleeding

PURPOSE OF REVIEW

Over 300 000 hospital admissions in the United States each year are due to patients with upper gastrointestinal (GI) bleeding (UGIB). Common etiologies of nonvariceal UGIB include peptic ulcers, mucosal erosions of the esophagus, stomach or duodenum, Mallory-Weiss tears, Dieulafoy lesions, upper GI tract malignancy, or other etiology.

RECENT FINDINGS

Peptic ulcers classified as Forrest Ia, Ib, or IIa require endoscopic hemostasis, while IIb ulcers may be considered for endoscopic clot removal with endoscopic treatment of any underlying major stigmata. Endoscopic hemostasis for ulcers classified as Forrest IIc or III is not advised due to the low risk of recurrent bleeding. Endoscopic hemostasis in ulcer bleeding can be achieved using injection, thermal, and/or mechanical modalities.

SUMMARY

This review focuses on the currently recommended endoscopic therapies of patients presenting with acute nonvariceal upper gastrointestinal hemorrhage.

[A Giant Gastric Perforation Occurring in the Normal Mucosa during Endoscopy in a Patient with Advanced Gastric Cancer]

The incidence of giant gastric perforation occurring during upper gastrointestinal endoscopy is exceedingly rare. Gastric perforation can arise from excessive air insufflation and is more prevalent in elderly patients with atrophic gastritis. Although giant gastric mucosal lacerations during diagnostic endoscopy have occasionally been reported, there are few reports of giant gastric perforation. The authors experienced a giant gastric perforation occurring in the normal mucosa during endoscopy in an 81-year-old woman with advanced gastric cancer. The patient had reduced gastric extensibility due to the advanced gastric cancer surrounding the entire lower part of her stomach. During continuous air insufflation, only the upper part of the stomach became overdistended, resulting in mucosal rupture and perforation. In addition, old age and the presence of atrophic gastritis contributed to the increased risk of mucosal rupture. The patient was treated successfully with endoscopic clips. This paper reports this case with a review of the relevant literature.

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.

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.

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.

Endoscopic band ligation therapy for upper gastrointestinal bleeding related to Mallory-Weiss syndrome

BACKGROUND

No consensus exists as to the best endoscopic treatment for Mallory-Weiss syndrome. Endoscopic band ligation is a readily available and easily learned technique. This prospective study evaluated the efficacy and safety of endoscopic band ligation therapy for Mallory-Weiss syndrome.

METHODS

From August 1998 to June 2005, a clinical trial assessed 37 patients with a diagnosis of Mallory-Weiss syndrome who had active bleeding, exposed vessels, or both. Their lesions were treated using endoscopic band ligation.

RESULTS

Endoscopic band ligation was successful in 36 of 37 cases, with a follow-up period ranging from 1 to 24 months. The remaining patient had severe liver failure and disseminated intravascular coagulation. The patient bled again at 12 h and subsequently died. Except for this case, no recurrent bleeding, perforation, or other complications occurred.

CONCLUSIONS

The study results suggest that endoscopic band ligation is an effective, safe, and easily learned procedure for treating upper gastrointestinal bleeding related to 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.