A Prospective Study of Patients with Bleeding Mallory Weiss Tears: Does Portal Hypertension Matter?

Abstract

Purpose: Mallory Weiss Tears (MWT) account for 5-10% of UGI bleeding (UGIB) cases. Little prospective data exist for outcomes in hospitalized MWT patients with UGIB with and without portal hypertension (PHTN) managed both medically and endoscopically. In patients with UGIB from MWT, our purposes were: 1) to report prevalences of different stigmata of hemorrhage (SRH) on emergency endoscopy, 2) for patients with or without PHTN, to compare efficacy and safety of different endoscopic therapies for those with major SRH and 3) to determine the effect of PHTN on 30-day outcomes. Methods: 100 hospitalized MWT patients with severe UGIB were enrolled in prospective studies. Medical therapy included protection of the airway in patients with altered mental or respiratory status or ongoing hematemesis; transfusions, anti-emetics and acid suppression in all patients; and octreotide for PHTN patients. Endoscopic treatments of MWT with major SRH included epinephrine injection, thermal contact probes and hemoclips for patients without PHTN; and sclerotherapy and/or band ligation of adjacent varices for PHTN patients. Results: MWT patients without PHTN (N=68) were more likely to drink alcohol & take either aspirin or Warfarin than MWT patients with PHTN (N=32). For all 100 patients, SRH were: active bleeding in 35% (6% spurting, 14% moderate active, 15% oozing), 5% non-bleeding visible vessel (NBVV), 15% adherent clot, 1% flat spot, and 44% clean lesion. 30-day rebleeding rates were not statistically significantly different in the two MWT groups: 18.8% with PHTN vs. 8.8% without PHTN. However, for both medical and endoscopic therapy, 30-day outcomes such as ICU days, length of hospitalization and mortality were all significantly higher in the patients with MWT and PHTN vs. those without PHTN (30-day death rate: 12.5% vs 1.5%, p< 0.018). For MWT patients treated endoscopically, 30-day rebleeding rates were similar: 18.8% PHTN vs. 16% without PHTN. However, 30-day mortality was significantly greater in the PHTN group: 18.8% with PHTN vs. 0% without PHTN. Endoscopic hemostasis was not associated with any complications such as perforation. Conclusion: 1. SRH of MWT's were active bleeding in 35%, adherent clot in 15%, NBVV in 5%, spot in 1%, and clean lesion in 44%. 2. Although different in patients with vs. without PHTN, endoscopic therapies were safe and effective for MWT with major SRH. 3. However, the 30-day mortality rate, ICU days, and length of hospital stay were all significantly increased for MWT patients with PHTN. (Study was supported by NIH NIDDK CURE DDRC Grant (AM 41301) and a Clinical VA Merit Review Grant).