Mallory-Weiss Lesions Research Articles

Diagnosis and therapy of non-variceal upper gastrointestinal bleeding.

Non-variceal upper gastrointestinal bleeding (UGIB) is defined as bleeding proximal to the ligament of Treitz in the absence of oesophageal, gastric or duodenal varices. The clinical presentation varies according to the intensity of bleeding from occult bleeding to melena or haematemesis and haemorrhagic shock. Causes of UGIB are peptic ulcers, Mallory-Weiss lesions, erosive gastritis, reflux oesophagitis, Dieulafoy lesions or angiodysplasia. After admission to the hospital a structured approach to the patient with acute UGIB that includes haemodynamic resuscitation and stabilization as well as pre-endoscopic risk stratification has to be done. Endoscopy offers not only the localisation of the bleeding site but also a variety of therapeutic measures like injection therapy, thermocoagulation or endoclips. Endoscopic therapy is facilitated by acid suppression with proton pump inhibitor (PPI) therapy. These drugs are highly effective but the best route of application (oral vs intravenous) and the adequate dosage are still subjects of discussion. Patients with ulcer disease are tested for Helicobacter pylori and eradication therapy should be given if it is present. Non-steroidal anti-inflammatory drugs have to be discontinued if possible. If discontinuation is not possible, cyclooxygenase-2 inhibitors in combination with PPI have the lowest bleeding risk but the incidence of cardiovascular events is increased.

Endoscopic Endoluminal Vacuum Therapy in Esophageal Perforation

Esophageal perforation is a serious disease with a high morbidity and mortality rate. Endoscopic vacuum therapy (EVT) is a new endoscopic treatment option, which is used to treat anastomotic leakages after rectal and esophageal resections. We report on 10 patients treated with EVT for esophageal perforation. Clinical and therapy-related data such as age, sex, duration of intensive care stay, length of hospital stay, reasons for perforation, EVT-associated complications, mortality, need for alternative treatment options, and course of infectious variables were analyzed. Ten patients were treated with 54 vacuum sponges that were placed in upper gastrointestinal defects. Causes for perforation were iatrogenic, spontaneous, or foreign body-associated. Mean number of sponge insertions was 5.4 (range, 2 to 12) with a mean period of 19 ± 14.26 days. Successful therapy was achieved in 9 of 10 patients. After successful primary treatment, 1 patient died during therapy as a result of general failure of the cardiovascular system. In 1 patient, surgical resection was necessary after repeated Mallory-Weiss lesions and minor perforations during the course of immunosuppressive therapy. In a third patient an endoscopic stent was inserted in the clean wound cavity after primary EVT. In this small trial EVT has been shown to be a safe and feasible therapy option for perforations of the upper gastrointestinal tract. If necessary, EVT can be combined with operative revision for better control of the local septic focus or used as a bridging procedure for wound conditioning before aggressive surgical treatment.

Acute Gastrointestinal Bleeding

Acid-base balance has been studied in 21 patients with acute upper gastrointestinal bleeding. A low plasma bicarbonate concentration was found in nine patients, accompanied in each case by a base deficit of more than 3 mEq/litre, indicating a metabolic acidosis. Three patients had a low blood pH. Hyperlactataemia appeared to be a major cause of the acidosis. This was not accompanied by a raised blood pyruvate concentration. The hyperlactataemia could not be accounted for on the basis of hyperventilation, intravenous infusion of dextrose, or arterial hypoxaemia. Before blood transfusion it was most pronounced in patients who were clinically shocked, suggesting that it may have resulted from poor tissue perfusion and anaerobic glycolysis. Blood transfusion resulted in a rise in lactate concentration in seven patients who were not clinically shocked, and failed to reverse a severe uncompensated acidosis in a patient who was clinically shocked. These effects of blood transfusion are probably due to the fact that red blood cells in stored bank blood, with added acid-citratedextrose solution, metabolize the dextrose anaerobically to lactic acid. Monitoring of acid-base balance is recommended in patients with acute gastrointestinal bleeding who are clinically shocked. A metabolic acidosis can then be corrected with intravenous sodium bicarbonate. one a probable Mallory-Weiss lesion, one a small-bowel reticulosis, and one had thrombocytopenia. In four patients the cause of bleeding was not identified. Arterial blood samples were taken within 36 hours of hospital admission, with the patients breathing air. No patient received any drugs known to cause a lactic acidosis. Though patients were supine at rest when the blood samples were taken, conditions were iiOt truly basal, as some of them were anxious and not all were fasting. In 14 patients an arterial blood sample was taken before blood transfusion, and in seven the first sample was taken during blood transfusion. The blood samples were analysed immediately for pH, carbon dioxide tension (Pco.), and oxygen tension (Poe) with a Radiometer electrode system at 37°C. Plasma bicarbonate concentration and base deficit were derived from pH and Pco2 by use of Siggaard-Andersen's (1963) nomogram. An aliquot of the blood sample was deproteinized at the bedside with icecold perchloric acid. Blood lactate and pyruvate concentrations were measured by means of a lactate dehydrogenase enzyme assay, the reagent kits supplied by Biochemica Test Combination being used as specified by the manufacturers (Boehringer und Soehne, 1967). For the purpose of this study arterial hypoxaemia has been defined as an arterial oxygen tension of less than 80 mm Hg, and clinical shock as the presence of cold, sweaty extremities in combination with a systolic blood pressure of less than 100 mm Hg.

938 Experience Matters: Higher Hospital Volume Is Associated with Lower Mortality in Acute Non-Variceal Upper Gastrointestinal Hemorrhage

Introduction: Acute non-variceal upper gastrointestinal hemorrhage (ANVUGIH) is a common medical emergency associated with significant morbidity, mortality and healthcare costs. It is among the leading gastrointestinal causes of hospitalization and death. Previous studies have shown a relationship between higher hospital or procedural volume and superior outcomes for complex surgical procedures. To our knowledge, ours is the first study to examine this relationship for ANVUGIH. Methods: We used data from the Nationwide Inpatient Sample (NIS) for the year 2004. Hospitalizations related to ANVUGIH were identified by the presence of a primary discharge diagnosis of bleeding peptic ulcer, gastritis with hemorrhage, Mallory-Weiss lesions, Dieulafoy's lesions, angiodysplasias of the stomach, hematemesis and melena through appropriate ICD-9-CM codes. Hospitals were then divided into low, medium, and high volume hospitals if they had 1 125, 126 250, or more than 250 annual hospitalizations for ANVUGIH. Results: There were a total of 135 366, 132 746, and 123 007 discharges with ANVUGIH from low, medium, and high volume hospitals respectively. Over half the patients in each volume category were 66 years or older. Bleeding peptic ulcer was the most common cause of the ANVUGIH, with a slightly higher proportion in high volume hospitals (35% vs. 32.4%, p=0.001). Patients at high volume hospitals were more severely ill with a higher proportion having acute renal failure (8.9% vs. 4.9%, p<0.001) or acute respiratory failure. Patients at high volume hospitals (OR 0.85, 95% CI 0.74 0.98) had significantly lower in-hospital mortality than patients at low volume hospitals. Patients at high volume hospitals were also more likely to undergo upper endoscopy than those at low volume hospitals on multivariate analysis (OR 1.52, 95% CI 1.36 1.69). A similar difference was seen in undergoing endoscopic intervention for control of hemorrhage (OR's 1.59 and 1.50 for medium and high volume hospitals respectively). In addition, patients at high volume hospitals were more likely to undergo endoscopy within 1 day of hospitalization compared to low volume hospitals (60.5% vs. 53.8%, Adjusted OR 1.28, 95% CI 1.02 1.61). Conclusion: Higher hospital volume is associated with lower mortality, and higher rates of endoscopy and endoscopic intervention in patients with ANVUGIH.

Diagnosis and Management of Upper Gastrointestinal Bleeding

Upper gastrointestinal (GI) bleeding is defined as bleeding proximal to ligament of Treitz. Its clinical presentations are hematemesis, melena stool, or even fresh bleeding per rectum. This paper reviews the diagnosis and treatment of upper GI bleeding. Selective literature review. Common causes of upper GI bleeding are peptic ulcer disease, bleeding from gastroesophageal varices, angiodysplasias, and Mallory-Weiss lesions. The most important diagnostic intervention is endoscopy, which allows therapeutic interventions if needed. Peptic ulcer disease is treated endoscopically with injection therapy and endoclips. Acute bleeding from oesophageal varices is treated by banding. Endoscopic treatment is accompanied by medical treatment with proton pump inhibitors for the treatment of peptic ulcer disease, and vasoactive drugs for the treatment of bleeding oesophageal varices. Modern endoscopy affords good localization of the bleeding site and successful treatment for most patients with upper GI bleeding.

Epidemiologie gastrointestinaler Blutungen bei älteren Patienten

The epidemiological pattern of gastrointestinal bleed in western countries has been steadily changing over the last few years given the rising prevalence of an elderly population. In a one year prospective study at a referral hospital in Zurich, Switzerland, hospitalised patients were investigated with regards to the epidemiology of gastrointestinal (GI) bleeding. Of 7406 hospitalisations, a total number of 224 GI bleeds were registered (53% women, mean age 71 +/- 16, 63% with relevant co morbidities). Of 197 patients with GI bleeds, 51% had upper and 37% lower gastrointestinal bleedings. 2% had concurrent upper and lower gastrointestinal bleedings and 10% remained unexplained. The following spectrum of lesions identified as bleeding sources was: 24% ulcer bleedings, 16% diverticular bleedings, 10% colitis, 10% esophagitis and 6% Mallory-Weiss lesions. The frequency of bleeds significantly increased with patient's age. In addition, diverticular bleeding in the elderly was highly associated with intake of Aspirin. The prognosis of gastrointestinal bleeding in elderly patients in this study was excellent with a bleeding associated mortality of only 3.1%.

Endoscopy for the Diagnosis of Acute Upper Gastrointestinal Bleeding

Diagnostic gastroscopy was performed on 337 patients for acute upper gastrointestinal bleeding, with 88% (296 of 337) diagnostic accuracy. Peptic ulcer disease was the cause of bleeding in 43% of the cases, erosive gastritis in 16%, and oesophagitis in 11%. Of the 289 patients, 40% had associated lesions, the commonest being gastritis (31), hiatal hernia (24), oesophageal varices (16), and oesophagitis (16). An oesophageal site of the bleeding was most often detected in the patients under 50 years of age (p less than 0.001) and a gastric site among those over 70 years (p less than 0.05). Mallory-Weiss lesions were significantly more often the cause of bleeding among the youngest patients than in other age groups (p less than 0.001). The bleeding lesion was located in the stomach in 60% of the women and in 42% of the men (p less than 0.01) and in the duodenum in 13% and 28% (p less than 0.01), respectively. The principal causes of this difference was the high incidence of gastritis in the women and duodenal ulcer in the men.

Mallory-weiss syndrome in a 10-month-old infant requiring surgery

Mallory-Weiss syndrome is infrequent in children. Intractable hemorrhage requiring surgery has been reported in only one 6-year-old child in the English literature. We present a case of intractable hemorrhage from a Mallory-Weiss lesion in a 10-month-old infant requiring surgery. The incidence, etiology, diagnosis, and treatment of Mallory-Weiss syndrome in children is discussed in relation to this case.

Gastrointestinal Hemorrhage

SINCE the introduction of fiberoptic endoscopy early in the 1960s, considerable evidence has been accumulated that suggests that fiberoptic endoscopy is the most accurate diagnostic technique for localizing the source of upper gastrointestinal tract (UGI) hemorrhage.^1,2Endoscopy has been noted to detect with high accuracy the presence of superficial mucosal disease, such as gastritis, varices, esophagitis, and Mallory-Weiss lesions, of the gastroesophageal junction.²The development of the flexible endoscope has sharply decreased morbidity and mortality caused by endoscopy. Nevertheless, noteworthy complications continue to be reported, including pharyngeal hematomas and lacerations, aspiration pneumonia, respiratory depression owing to intravenous administration of medication, and GI perforation and bleeding from endoscopic biopsies. The clinical impact of emergency endoscopy in bleeding patients has been the subject of much controversy, with little to suggest that the morbidity and mortality of GI hemorrhage have been appreciably reduced by the use of endoscopy.^3,4 The radiological

Mallory-Weiss Lesion in Identical Twins

Mallory-Weiss Lesion in Identical Twins

Stigmata of recent haemorrhage in diagnosis and prognosis of upper gastrointestinal bleeding

In 277 consecutive episodes of suspected upper gastrointestinal bleeding, lesions bearing stigmata of recent haemorrhage (stigmata) were found by endoscopy in 110 (47%) out of 233 patients who were judged to have bled; 78 (33%) had lesions without stigmata, and in 45 (19%) no lesion was seen. Results in 176 entirely unselected admissions for upper gastrointestinal bleeding were similar.Forty-eight chronic duodenal and 41 chronic gastric ulcers were identified by endoscopy. Stigmata were found in 27 (56%) and 33 (80%) of these cases respectively. Sixteen patients had multiple lesions, and in 12 (75%) the presence of stigmata permitted diagnosis of the source of the haemorrhage. Stigmata were more likely to be seen in cases of duodenal ulcer, Mallory-Weiss lesions, and oesophageal varices when endoscopy was performed within 12 hours of bleeding, but were as common in cases of gastric ulcer after longer intervals.In the absence of stigmata one out of 21 patients with duodenal ulcer had further haemorrhage and one other needed emergency surgery; no patient with gastric ulcer had further haemorrhage or needed emergency surgery. In contrast, when stigmata were present 15 of the 27 patients with duodenal ulcer (56%) had further haemorrhage and 17 (63%) needed emergency surgery; of the 33 patients with gastric ulcer, 10 (30%) had further haemorrhage and 15 (45%) required emergency surgery. Superficial mucosal lesions may have been the source of haemorrhage when an ulcer unmarked by stigmata was seen at endoscopy. Stigmata were superior to any other single factor or combination of factors in predicting rebleeding and the need for emergency surgery.

THE MALLORY‐WEISS LESION A FIVE‐YEAR EXPERIENCE

A retrospective survey has been made of patients with the Mallory-Weiss lesion who presented with upper gastrointestinal tract bleeding during the period 1972 to 1976. The lesion was diagnosed endoscopically in 78 cases, representing 7.7% of the total number of patients admitted with upper gastrointestinal tract bleeding. Patients ranged in age from 18 to 86 years (mean 43 years). The male-female ratio was 3:1. A history of retching and vomiting clearly preceded the bleeding in 60 patients. Significant alcohol intake within 48 hours of bleeding was reported in 53% of patients. Other upper gastrointestinal tract conditions, or migraine, may have induced vomiting in some instances. Previously known Mallory-Weiss lesions were rare (two patients), but 21% of patients had well documented past upper gastrointestinal tract bleeding from other causes. The tears were situated at the cardio-oesophageal junction in 47% of patients and were entirely gastric in 30%; 23% were oesophageal. Blood replacement was required in 31 patients (40%), and 16 of these were transfused with five or more units. Of those patients requiring transfusion, half had other significant pathological lesions. The mean hospital stay was four days and prolonged stay in hospital was usually necessary only in the presence of other disease. In no instance was surgery required primarily to control bleeding from mucosal tears. This study suggests that the Mallory-Weiss lesion is a relatively common cause of upper gastrointestinal tract bleeding, but that it is usually a benign condition, unless it complicates some other disorder.

Hiatus Hernia and the Location of Mallory-Weiss Lesions

Hiatus Hernia and the Location of Mallory-Weiss Lesions

Lesions Brought on by Vomiting: The Effect of Hiatus Hernia on the Site of Injury

From an extensive review of the published cases of lesions of the esophagus and stomach brought about by vomiting and a supplemental review of local experience with the Mallory-Weiss syndrome, the influence of hiatus hernia on the lesion site can now be defined. Mallory-Weiss lesions located in the gastric cardia are commonly associated with hiatus hernia. By contrast, those occurring in the distal esophagus and those that overlie the cardioesophageal junction are only rarely associated with hernia. The Boerhaave lesion occurs most probably in the absence of hiatus hernia and in 2 of 3 previously reported cases wherein a hernia was present, a combined gastroesophageal rupture occurred. A newly recognized postemetic form of gastric rupture is clearly distinguished from other causes of this lesion and its characteristic location is described. A unifying hypothesis is proposed in which the location of lesions occurring during emesis is determined by the presence of a hiatus hernia during retching.

DIAGNOSIS OF MALLORY-WEISS LESIONS: A Common Cause of Upper Gastrointestinal Bleeding

Mallory-Weiss lesions were considered to be the source of bleeding in 21(13·4%) of 157 unselected patients admitted to a general medical unit because of suspected upper gastrointestinal hæmorrhage over a period of 30 months. They represented 16·7% of the 126 patients in whom there was ultimately good evidence of upper gastrointestinal blood-loss. In the total series of 200 suspected bleeding episodes the incidence was 11·5%. It is suggested that endoscopy of the upper gastrointestinal tract, performed as early as possible after resuscitation, enables the diagnosis of the Mallory-Weiss lesion to be made, shows that it is a relatively common source of hæmorrhage, and establishes whether bleeding has stopped, thereby helping to identify patients who can be managed without transfusion and those who are likely to require surgery.

Postemetic hematomas: A variant of the Mallory-Weiss syndrome

Of forty-four patients with the Mallory-Weiss syndrome, nine (20 per cent) had endoscopic evidence of small submucosal hematoma(s) lying in or adjacent to the region of the the tear. These small hematomas are believed to occur most commonly as a variant of the Mallory-Weiss lesion.

Mallory-Weiss syndrome in perspective.

Nineteen patients with the Mallory-Weiss lesion diagnosed by panendoscopy are presented. This represents 10.5% of 180 acute upper-gastrointestinal bleeders. Only 36.8% of these 19 patients had a history of heavy ethanol intake and 26% had hiatus hernias. In addition to the Mallory-Weiss lesion, abnormalities in 63% were noted on endoscopy. None of the patients required surgery for control of the bleeding. Two patients were treated with selective arterial-vasopressin infusion. The importance of a high index of suspicion for this lesion in spite of the lack of a classical alcoholic or recurrent retching history and the value of intensive medical therapy, including early panendoscopy, is emphasized.

Mallory-Weiss Syndrome

A review of seven years' experience with upper gastrointestinal bleeding at a large metropolitan hospital showed 36 cases of the Mallory-Weiss lesion (4.5% of all cases of upper gastrointestinal hemorrhage during this period). Diagnosis was established with endoscopy or surgery. Nineteen percent of patients with the Mallory-Weiss syndrome required surgery, and only 61% required transfusion. These data suggest that the Mallory-Weiss syndrome has a wider and more benign clinical spectrum than has been reported previously. ( JAMA 230:1674-1675, 1974)

New approaches to the radiological diagnosis of Mallory-Weiss syndrome.

Abstract It is generally stated that the role of radiology in the diagnosis of Mallory-Weiss syndrome is to exclude any other lesion. Correct pre-operative diagnosis was established in two patients by selective coeliac arteriography. The diagnostic principle of arteriography in the actively bleeding patient is to demonstrate the point of contrast medium (blood) extravasation. This examination is independent of the depth, size and location of the bleeding point, or of the presence of food or blood clot in the viscus. It is the examination of choice if a Mallory-Weiss syndrome is suspected. By using arteriography the radiologist can reach the correct preoperative diagnosis in patients bleeding from Mallory-Weiss lesions. This significantly improves the survival rate of such patients.

ACUTE FATTY LIVER OF PREGNANCY WITH HEPATIC COMA AND MALLORY-WEISS SYNDROME: REPORT OF A CASE.

A case of acute fatty liver of pregnancy with unusual complications is presented. These include upper gastrointestinal bleeding due to a Mallory-Weiss lesion, coagulation disturbances, and hepatic encephalopathy with hyperammonemia. The patient survived after massive corticosteroid therapy.