Mallory-Weiss syndrome. Characterization of 75 Mallory-weiss lacerations in 528 patients with upper gastrointestinal hemorrhage.

Seventy-five Mallory-Weiss lacerations were visualized endoscopically in 58 of 528 patients evaluated acutely for upper gastrointestinal bleeding. The Mallory-Weiss mucosal laceration is more common than generally recognized, is usually associated with hiatal hernia and a prodrome of retching or vomiting, and the ingestion of alcohol or acetylsalicyclic acid, or both. The lacerations are most commonly gastric and are associated with other mucosal lesions which may in fact be the instigating cause of the retching and vomiting. Although blood loss may be considerable, 90% or more patients with this lesion can be managed nonsurgically with appropriate blood component replacement and occasional use of systemic pitressin. There was one fatality in this series of 58 patients with Mallory-Weiss lacerations.     

Mucosal tears at the oesophagogastric junction (the Mallory-Weiss syndrome)

This is a re-appraisal of the supposedly rare Mallory-Weiss syndrome in which 11 patients with mucosal tears at the oesophagogastric junction are described. The fact that these cases were collected from general hospitals within a short period suggests that the condition is more common than supposed and may account for a considerable proportion of the 20 to 25% of patients with upper gastrointestinal bleeding in whom no radiological abnormality can subsequently be found.Of the 11 patients, eight presented with gastrointestinal bleeding, two with mediastinitis, and one without relevant symptoms. The classical history of antecedent vomiting before the bleeding was obtained in only four patients, its absence not excluding the diagnosis. The presence of a small hiatal hernia in four patients appeared to predispose to mucosal tears as did mucosal atrophy occurring with advancing age. Some experimental findings pertaining to the mechanism of the tears are presented.     

胶囊内镜检查后上消化道大出血1例报道

46岁男性患者接受胶囊内镜检查后发生上消化道大出血，胃镜检查提示贲门黏膜撕裂，给予抗休克和三腔双囊管压迫等治疗措施后出血停止。胶囊内镜在胃内滞留诱发患者呕吐，剧烈的呕吐导致贲门黏膜撕裂引发上消化道大出血。因此对于胶囊内镜滞留胃内的患者要警惕出血的可能。     

Prospective evaluation of immediate versus delayed refeeding and prognostic value of endoscopy in patients with upper gastrointestinal hemorrhage.

The effects of immediate vs. delayed refeeding and the prognostic value of endoscopic findings in patients with major upper gastrointestinal hemorrhage were assessed in a prospective randomized study. Entry criteria were clinical evidence of major hemorrhage and endoscopic evidence of a Mallory-Weiss tear or an ulcer with a clean base, flat spot, or clot. Two hundred fifty-eight patients were randomly assigned to groups receiving a regular diet immediately or nothing by mouth for 36 hours, then clear liquids for 12 hours, and a regular diet thereafter. Outcomes in the immediate and delayed refeeding groups were comparable: rebleeding occurred in 4% vs. 5%; urgent intervention, 2% vs. 2%; and deaths, 1% vs. 1%, respectively. Rebleeding occurred in 2 (2%) of 96 patients with cleanbased ulcers, 5 (8%) of 65 with ulcers with spots, 3 (14%) of 21 with ulcers with clots (P = 0.05, 3 x 2 chi2 test), and 1 (2%) of 66 with Mallory-Weiss tears. It is concluded that the time of refeeding does not influence the hospital course of patients with a low risk of recurrent bleeding. Patients with clean-based ulcers or nonbleeding Mallory-Weiss tears may be refed and discharged home immediately after stabilization.     

The mallory-weiss syndrome: Evaluation by early endoscopy of its clinical picture and its incidence in upper gastrointestinal hemorrhage

Summary 1. In a prospective study of upper gastrointestinal hemorrhage, 297 cases were examined endoscopically. Eight instances of gastric or esophageal tears were noted. Over the 29-month period during which the study was carried out, there were 49,760 admissions to this municipal teaching hospital. The incidence of gastroesophageal tears was 2.7% of all upper gastrointestinal bleeders and 0.016% of all admissions.2. Early endoscopy was of great value in establishing a rapid and accurate diagnosis of the lesion.3. In 2 instances bleeding did not result from the demonstrated tears, but was due to coexistent acute gastric erosions.4. In 4 other cases, bleeding from the tear stopped spontaneously; one of these was operated electively for a nonbleeding duodenal ulcer. Surgical intervention for continued bleeding was necessary in 2 patients, one of whom died.5. An initial conservative approach to therapy of the Mallory-Weiss syndrome is suggested, provided the diagnosis is ascertained by early esophagogastroscopy. Continued bleeding will obviously dictate surgical intervention.Supported in part by Training Grant TI-AM-5237-01 from the National Institute of Arthritis and Metabolic Disease, N.I.H., U. S. Public Health Service, and Contract U-1373 from the Health Research Council of the City of New York.U. S. Public Health Service Trainee in Gastroenterology. Present address: Beilinson Hospital, Petah Tikvah, Israel.     

Therapeutic endoscopy for nonvariceal gastrointestinal bleeding

This article reviews the role of therapeutic endoscopy in the diagnosis and treatment of nonvariceal upper and lower gastrointestinal (GI) hemorrhage. The initial approach to patients with GI bleeding is reviewed. Endoscopic treatment of various stigmata of recent peptic ulcer hemorrhage is discussed in detail. Management of less common causes of nonvariceal bleeding, such as Dieulafoy's lesions, Mallory-Weiss tears, angiomas, and bleeding colonic diverticula is described. Recommendations for endoscopic techniques are based on the results of UCLA-CURE hemostasis studies.     

Mallory-Weiss Syndrome—Revisited

Six patients (three women and three men) who had upper gastrointestinal hemorrhage due to Mallory-Weiss syndrome are described. Retching was the most common precipitating factor (5/6) followed by vomiting (2/6). Basic underlying causes for either retching or vomiting were probable excess alcohol consumption (3/6), side-effects of oral or parentral medication (2/6) and over-indulgence in eating after partial gastrectomy (1/6). The two most important factors leading to confirmation of the diagnosis were: 1. History of events prior to the onset of upper gastrointestinal hemorrhage and 2. early panendoscopy. One noted feature of the present series is the high incidence of other silent co-existing pathological lesions at the time of endoscopic examination. Upper gastrointestinal hemorrhage was characterized as mild to moderate (300-500 cc.) in three patients and moderate to severe (1,000-2,000 cc.) in another three patients. All recovered under medical management and none required surgical intervention. It is becoming increasingly evident that such a benign outcome in Mallory-Weiss syndrome is more common than previously recognized.     

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.     

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.     

Source of upper gastrointestinal bleeding in patients with esophageal varices seen at endoscopy

Many claim that upper gastrointestinal hemorrhage in patients with varices is frequently not of variceal origin. Such teaching is contrary to our experience. We therefore reviewed the records of 127 consecutive patients with 165 episodes of acute upper gastrointestinal bleeding who were found to have esophageal varices by endoscopy. Varices were the only potential site of the index bleed in 101 of the 127 patients (79.5%). In addition to varices, other potential sites of bleeding were gastric ulcer in 9 (7%), Mallory-Weiss tear in 4 (3.1%), duodenal ulcer in 3 (2.3%), and multiple gastroduodenal erosions in 10 (7.8%). We used the characteristics of the clinical presentation (e.g., varix seen bleeding) and the known natural course of the variceal bleeding to attempt to define the site of bleeding in the group with more than one potential site. In 15 we could make a judgment as to the likely source: In 9 it was variceal and in 6 nonvariceal. When varices are seen at endoscopy in a patient with a major hemorrhage, they are responsible for the bleeding in greater than 80% of cases.     

Upper GI Bleeding in an Emergency Hospital: Etiology,Prognosis and Improved Survival by Endoscopic Hemostasis

Acute upper gastrointestinal bleeding (UGIB) is a frequent diagnosis prompting hospital admission or complicating another preexisting condition. This report examines the experience of an urban medical center in the utilization of endoscopy and endoscopic hemostasis in the diagnosis and management of UGIB over a four-year period. The first portion of this study examines 562 admissions to a single institution with UGIB. The most common causes of bleeding were acute gastric mucosal lesions (AGML), 24%; esophageal varices (EV), 22%; gastric ulcers, 19%; duodenal ulcers, 14%; Mallory-Weiss tears, 11%; and esophagitis, 3%. Nonoperative treatment was sufficient in the majority of patients (89.5%). Endoscopic therapy was utilized in 144 patients (26%), of whom 12 required a subsequent operation. Fifty-eight patients (10.5%) underwent surgery; however, emergent operations were required in only 2.5% of the patients. Factors correlating with mortality included shock at the time of admission (SBP < 80), transfusion requirements of > 5 U PRBC, and presence of EV (each p < 0.001). The second part of this study examines the effect of thrombogenic sclerotherapy on both short and long-term survival in 101 patients referred with bleeding esophageal varices. Alcoholic cirrhosis was responsible for the majority (88%) of EV, and most patient were Child's C classification (84%). In long-term follow-up, rebleeding was significantly reduced (p = 0.03) in patients compliant with follow-up sclerotherapy. A trend toward decreased mortality was noted in patients compliant with sclerotherapy and in those who avoided further alcohol usage.     

Mechanical gastritis involving the cardia: the trauma of retching and vomiting

In two patients, frequent retching and vomiting preceded acute upper gastrointestinal hemorrhage. Congestion and edema were limited to the prolapsed portion of the stomach, the cardia, where discrete erosions and small shallow ulcers were seen. At endoscopy, prolapse of the gastric mucosa into the esophageal lumen was quite evident whenever the patients retched. The endoscopic features and pathogenesis of Mallory-Weiss syndrome were readily differentiated. It seemed probable that repeated retching causing intussusception of the cardia of the stomach can mechanically produce gastritis and should be a recognizable cause of acute upper gastrointestinal bleeding. I take this entity to be an independent superficial mucosal disease of the stomach.     

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.     

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 bad 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.     

Gastrointestinal hemorrhage in patients with AIDS

Gastrointestinal (GI) bleeding is a relatively infrequent complication seen in patients with AIDS. As with non-HIV-infected individuals, upper GI bleeding is much more common than lower GI bleeding. In patients with AIDS, upper GI bleeding can result from etiologies related to underlying HIV infection [cytomegalovirus (CMV), Kaposi's sarcoma, idiopathic esophageal ulcers, etc] or be unrelated to HIV infection (peptic ulcer, portal hypertension, Mallory-Weiss tear, etc.). Lower GI bleeding is caused predominantly by etiologies related to underlying HIV disease; CMV colitis is the most common cause. In contrast to non-HIV-infected individuals, hemorrhoids and anal fissures can result in significant bleeding in AIDS patients because of associated thrombocytopenia. Management of GI bleeding in AIDS patients is similar to patients without HIV infection, and includes resuscitation, identification of the bleeding source, achieving hemostasis, and preventing recurrent bleeding. Several etiologies that cause GI bleeding in patients with AIDS can be diagnosed through endoscopy, either by their characteristic endoscopic appearance or mucosal biopsies.     

Frequency, significance and therapy of the Mallory-Weiss syndrome in patients with portal hypertension

The files of patients who underwent emergency endoscopy in a 2-yr period (January 1985 to January 1987) in the Heinz-Kalk Hospital were analyzed to establish the frequency, significance and therapy of the Mallory-Weiss syndrome associated with portal hypertension, an association observed in 55 of 339 patients (16.2%). Portal hypertension was caused by cirrhosis in 53 patients and by a prehepatic block in two patients. For 21 of these patients (37%) with portal hypertension, Mallory-Weiss syndrome was the first bleeding manifestation. They numbered 6.2% of the whole population. In the remaining 34 patients (63%) sclerotherapy treatment had been previously performed. No lesions that suggested peptic esophagitis were seen in these 55 patients, although in 25 of them (45.4%) a gastroesophageal reflux was observed. The frequency of bleeding from a Mallory-Weiss tear was significantly higher in patients with advanced liver disease, particularly with Child-Pugh classifications C and B. In patients with prehepatic block, a hemorrhage from a Mallory-Weiss tear may occur, but the frequency is significantly lower than it is in patients with cirrhosis. The bleeding tear was treated by transendoscopic esophageal and cardial wall sclerosis (paravariceal technique) and was, in all cases, successfully controlled. Mallory-Weiss syndrome is observed more frequently in patients with portal hypertension and cirrhosis. Gastroesophageal reflux apparently does not play a major role in the pathogenesis of this syndrome. It may simply be the manifestation of an abnormal gastroesophageal function. Mallory-Weiss syndrome can also be observed as a cause of rebleeding in patients treated with chronic sclerotherapy. Paravariceal endoscopic sclerotherapy is apparently the treatment of first choice to stop hemorrhage.     

Transcatheter therapy of gastrointestinal arterial bleeding

Summary Transcatheter therapy for arteriocapillary gastrointestinal bleeding is often an effective form of treatment. The choice of transcatheter therapy (ie, vasoconstrictor or occlusive) often is dependent on the etiology and location of bleeding. Vasopressin is a generally safe form of treatment which is often successful in treating bleeding secondary to gastritis, Mallory-Weiss mucosal tears, and diverticular disease. It is less effective in treating bleeding peptic ulcers, neoplastic bleeding, or bleeding when clotting abnormalities exist. Occlusive therapy is an effective alternate form of therapy in selected circumstances. Ischemic complications from vasoconstrictor and embolic therapy may occur and require appropriate caution and discretion with their use.     

Hemorrhage from gastric mucosal tears complicating cardiopulmonary resuscitation

We observed at autopsy two patients in whom clinically significant gastrointestinal bleeding occurred from gastric mucosal tears following closed chest cardiac massage. Review of autopsy files showed that, when the Mallory-Weiss syndrome is excluded, linear mucosal tears along the lesser curvature of the stomach occur in about 2% of patients given cardiopulmonary resuscitation; similar lesions have not been observed in patients not subjected to resuscitation. The localization of the tears along the lesser curvature of the stomach is probably the consequence of the catenoidal configuration of that region. The importance of the mucosal tears lies in their propensity to hemorrhage if resuscitation is successful.     

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.     

New and old methods for endoscopic control of nonvariceal upper gastrointestinal bleeding

Candidates for endoscopic therapy of nonvariceal upper gastrointestinal bleeding include patients with bleeding ulcers, Mallory-Weiss tears, angiodysplasia, and Dieulafoy or other lesions with active bleeding, non-bleeding visible vessel, or adherent clot. Continuous infusion of intravenous proton pump inhibitors lowers rebleeding risk after endoscopic therapy. Of standard methods, a combination of epinephrine injection with thermal coagulation (bipolar or heater probe) has been shown to be optimal, with lower rebleeding rates (5-10%) than for either method alone. Endoscopic clipping is an appealing technique, but comparative data with other methods are limited and conflicting. Band ligation is also suitable for many non-ulcer lesions without a firm base. Argon plasma coagulation is most useful for lesions with a large surface area such as watermelon stomach, but of uncertain advantage for other nonvariceal bleeding lesions. Regardless of method used, technical expertise plays a role in the outcomes of therapy. Of future interest are techniques to image beneath the surface and predict rebleeding risk, and improved methods of mechanical hemostasis.