Mallory-Weiss Research Articles

Conservative Management of an Iatrogenic Esophageal Tear in Kenya.

Since its description over 250 years ago, diagnosis of esophageal perforation remains challenging, its management controversial, and its mortality high. This rare, devastating, mostly iatrogenic, condition can quickly lead to severe complications and death due to an overwhelming inflammatory response to gastric contents in the mediastinum. Diagnosis is made with the help of esophagograms and although such tears have traditionally been managed via aggressive surgical approach, recent reports emphasize a shift in favor of nonoperative care which unfortunately remains controversial. We here present a case of an iatrogenic esophageal tear resulting from a routine esophagoscopy in a 50-year-old lady presenting with dysphagia. The esophageal tear, almost missed, was eventually successfully managed conservatively, thanks to a relatively early diagnosis.

Spontaneous Pneumomediastinum: An Unusual Pulmonary Complication in Anorexia Nervosa

Spontaneous pneumomediastinum (PM) is an uncommon condition in which free air enters the mediastinum. This usually occurs either through esophageal tears after vigorous vomiting, or after alveolar rupture subsequent to a rapid increase in intra-alveolar pressure. Spontaneous PM is a rare entity in anorexia nervosa (AN) and self-induced vomiting is often the cause of PM in patients with AN. We experienced a case of spontaneous PM in an anorexic adolescent, in whom vomiting was not the cause of PM.

Safety and efficacy of carbon dioxide insufflation during gastric endoscopic submucosal dissection.

To compare the safety and efficacy of carbon dioxide (CO2) and air insufflation during gastric endoscopic submucosal dissection (ESD). This study involved 116 patients who underwent gastric ESD between January and December 2009. After eliminating 29 patients who fit the exclusion criteria, 87 patients, without known pulmonary dysfunction, were randomized into the CO2 insufflation (n = 36) or air insufflation (n = 51) groups. Standard ESD was performed with a CO2 regulation unit (constant rate of 1.4 L/min) used for patients undergoing CO2 insufflation. Patients received diazepam for conscious sedation and pentazocine for analgesia. Transcutaneous CO2 tension (PtcCO2) was recorded 15 min before, during, and after ESD with insufflation. PtcCO2, the correlation between PtcCO2 and procedure time, and ESD-related complications were compared between the two groups. Arterial blood gases were analyzed after ESD in the first 30 patients (12 with CO2 and 18 with air insufflation) to assess the correlation between arterial blood CO2 partial pressure (PaCO2) and PtcCO2. There were no differences in respiratory functions, median sedative doses, or median procedure times between the groups. Similarly, there was no significant difference in post-ESD blood gas parameters, including PaCO2, between the CO2 and air groups (44.6 mmHg vs 45 mmHg). Both groups demonstrated median pH values of 7.36, and none of the patients exhibited acidemia. No significant differences were observed between the CO2 and air groups with respect to baseline PtcCO2 (39 mmHg vs 40 mmHg), peak PtcCO2 during ESD (52 mmHg vs 51 mmHg), or median PtcCO2 after ESD (50 mmHg vs 50 mmHg). There was a strong correlation between PaCO2 and PtcCO2 (r = 0.66; P < 0.001). The incidence of Mallory-Weiss tears was significantly lower with CO2 insufflation than with air insufflation (0% vs 15.6%, P = 0.013). CO2 insufflation did not cause any adverse events, such as CO2 narcosis or gas embolisms. CO2 insufflation during gastric ESD results in similar blood gas levels as air insufflation, and also reduces the incidence of Mallory-Weiss tears.

Diagnosis and treatment of Mallory-Weiss syndrome: Our experience with 64 cases

Diagnosis and treatment of Mallory-Weiss syndrome: Our experience with 64 cases

Boerhaave′s syndrome presented with right-sided hydropneumothorax and hoarseness of voice: A case report

Boerhaave's syndrome is a rare and sometimes life-threatening condition characterized by lower esophageal tear due to a sudden rise of intraluminal pressure, and it is usually presented with a history of forceful vomiting, abdominal or chest pain, and sometimes subcutaneous emphysema. Atypical and delayed presentation is also not uncommon. A high index of suspicion is needed for diagnosis. The diagnosis is confirmed by contrast esophagogram or contrast computed tomography (CT) of the chest. Mortality rates could be as high as nearly 20-40% even in the treated cases. In this article, we report a case of a 57-year-old male, who is a smoker as well as an alcoholic, with right-sided hydropneumothorax presenting with dyspnea, epigastric pain, hoarseness of voice, and features of shock. Boerhaave's syndrome was suspected on finding food particles in pleural fluid that contained very high salivary amylase level. The diagnosis was confirmed with a sterile methylene blue contrast study.

Management of Upper Gastrointestinal Bleed

Upper gastrointestinal bleed (UGIB) causes significant morbidity and mortality the world over. The two main causes have been due to increasing nonsteroidal anti-inflammatory drug use along with the high prevalence of Helicobacter pylori infection in patients with peptic ulcer and bleeding from gastroesophageal varices due to portal hypertension. Other causes of esophageal tears, gastrointestinal malignancy, and arteriovenous malformations also contribute to the morbidity and motality. Rapid assessment, resuscitation, and early endoscopy form the basis of early management of patients with severe bleeding. Risk stratification is based on clinical assessment and endoscopic findings. Early Upper gastrointestinal endoscopy (UGIE) (within 24 h of presentation) confirms the diagnosis and allows for targeted endoscopic treatment, which results in reduced morbidity, hospital stay, the risk of recurrent bleeding, and need for surgery. Despite successful endoscopic therapy, re-bleeding remains a risk and a second attempt at endoscopic therapy is recommended in most. Arteriography with embolization can serve as an extremely useful therapeutic option. Thanks to excellent medical and endoscopic control, surgery for UGIB is rarely required nowadays.

Gastroesophageal and hemorrhagic complications associated with intraoperative transesophageal echocardiography in patients with model for end-stage liver disease score 25 or higher.

To investigate major gastroesophageal and hemorrhagic complications that may be related to intraoperative transesophageal echocardiography (TEE) in liver transplant (LT) patients with high model for end-stage liver disease (MELD) score 25 or higher. Retrospective. Single institution university setting. Of 906 transplant recipients, 656 who had MELD score 25 or higher were included for analysis. Patient demographics, pre- and intraoperative characteristics, and major gastroesophageal and hemorrhagic complications were compared between patients with and without TEE. Sixty-six percent (433 patients) had intraoperative TEE and 34% (223 patients) did not. One patient in the TEE group had a major gastroesophageal complication (Mallory-Weiss tear). Eleven patients required postoperative gastrointestinal consultation. These patients were distributed evenly between the TEE and non-TEE groups. Eighteen (2.8%) had major hemorrhagic complication (defined as bloody nasogastric output>500 mL in 24 hours postoperatively). Multivariate analysis showed alcoholic cirrhosis had 5.3 higher odds of post-transplant gastroesophageal hemorrhage compared with other indications for transplant (95% confidence interval 1.8-15.8, p<0.001). TEE was not associated with an increased likelihood of major hemorrhagic complication after LT. The authors demonstrated that the incidence of major gastroesophageal and hemorrhagic complications following intraoperative TEE in LT patients with MELD score 25 or higher was low.

A Retrospective Analysis and a New Type of Clinical Classification of Mallory-Weiss Syndrome

Introduction: Mallory-Weiss Syndrome (MWS) is one of the important causes of upper gastrointestinal bleeding and it is mainly induced by severe vomiting. Now the causes of MWS have changed partly and the treatment of which has almost turned to endoscopic therapy. A new type of clinical classification may be helpful for the evaluation of MWS. Methods: Retrospective analysis of 64 MWS cases in our hospital from January 2010 to March 2014. The causes, endoscopic findings, treatment and prognosis were evaluated according to a new type of clinical classification. Results: The ratio of male to female in 64 MWS cases is 3.3:1 and the average age is 50.2 years old. 53.1% of MWS is caused by over drinking or inappropriate diet occasionally. 37.5% of MWS is caused by underlying gastric diseases such as peptic ulcer (26.6%), gastric cancer (6.3%) or Dieulafoy disease (4.7%). And 9.4% of MWS is caused by endoscopic examination or treatment. 62.5% of MWS developed only one lesion of cardia and/or lower esophagus and 29.7% developed 2˜3 lesions. The lesions may happen in all the four walls of cardia and/or lower esophagus and the right wall is relatively common location (32.5%). According to a new type of clinical classification introduced here during endoscopic examination, 17.2% of MWS was found out with active bleeding (Type A) such as spouting, pulsating or oozing. 21.9% was found out with fresh blood clot (Type B) and 32.8% with old blood clot (Type C). The rest 28.1% was found with line ulcer or scar (Type D). All Type A patients were treated with endoscopic metal clip treatment and partly combined with noradrenalin spraying. Part of Type B patients were treated with metal clip or noradrenalin spraying. Only one patient of Type A died because of suspected underlying intestinal bleeding and all other patients were cured. Conclusion: Underlying gastric diseases are also important causes of MWS and easy to be ignored especially Dieulafoy disease. Endoscopic metal clip is the first choice for treatment of MWS and the new type of clinical classification is useful for evaluation.

Clinical and endoscopic profile of patients with upper gastrointestinal bleeding at tertiary care center of North India

Abstract Background: Upper gastrointestinal bleeding (UGIB) is a common medical emergency associated with significant morbidity and mortality. The presentation of bleeding depends on the amount and location of hemorrhage and the endoscopic profile varies according to different etiology. Despite advancements in medical intervention UGIB still carries considerable morbidity, mortality and economic burden on health care system. At present, there is limited epidemiological data on UGIB and associated mortality from India. Aims: The aim was to study clinical, endoscopic profile, and associated mortality in patients presenting with UGIB. Materials and Methods: One hundred and fourteen patients came to Emergency Department with UGIB during the study period and were subjected to endoscopy to identify the etiology. The clinical and endoscopic profile was analyzed and mortality pattern was studied. Results: The mean age of patients was 49 ± 14.26. Majority of them were males (83.33%) and male to female ratio was 5:1. The most common cause of UGIB was portal hypertension related (Esophageal and gastric varices) seen in 56.14% of patients, peptic ulcer-related bleed was seen in 14.91% patients, gastric erosions were responsible for bleed in 12.28% patients, Mallory–Weiss tear was seen in 8.77% cases, gastric malignancy accounted for 4.38% of cases, Dieulafoy’s lesion was responsible for bleed in 1.75% cases and 1.75% had Duodenal polyp. The mortality rate because of UGIB in our cohort of patients was 21.05%. Conclusions: In the present study, variceal bleed was the most common cause of UGIB, followed by peptic ulcer bleed. Overall mortality was seen in 21.05% of cases; however, majority of mortality was seen in portal hypertension related bleeding.

Use of Golimumab in Pregnancy in Ulcerative Colitis

Introduction: We present a case of a 26-year-old white woman who was diagnosed with ulcerative colitis in 2007 after presenting with bloody diarrhea and left-sided colitis. She was treated with mesalamine. Despite poor adherence, she had only mild flares until December 2009. At this time, she had a flare, which required a steroid taper and initiation of azathioprine. She did well until a hospitalization in May 2010 for worsening of bloody diarrhea, severe nausea, vomiting, respiratory failure, and an esophageal tear from presumed severe side effect from azathioprine (after which it was discontinued). She underwent colonoscopy at that time, showing pancolitis, and was started on infliximab, which led to clinical remission. However, over time she developed additional symptoms, and in 2011, she underwent a colonoscopy showing pancolitis. Her infliximab was escalated to 10 mg/kg every 6 weeks. She returned to clinical remission and became pregnant March 2013. She required a hospitalization in her first trimester for a flare requiring transfusion of 4 units of packed red blood cells for severe iron deficiency anemia (hemoglobin of 5 g/dL). Infectious etiologies were ruled out and the patient was started on intravenous steroids, which improved her diarrhea from 15-10 bowel movements per day. She was then switched to adalimumab and oral prednisone. She continued to have hematochezia, diarrhea, and urgency, including nocturnal symptoms. She required a second hospitalization during her second trimester with 2 more units of packed red blood cell transfusions, repeat intravenous steroid infusion, and eventual discharge on oral prednisone 40 mg per day. She was followed by a high-risk obstetrician and her baby was found to have intrauterine growth restriction on ultrasound. Due to lack of efficacy on adalimumab, even with dose escalation to 40 mg weekly, she was then started on golimumab during her 26th week of gestation. After induction therapy, she was able to taper off prednisone completely and had resolution of her gastrointestinal symptoms with no diarrhea, no hematochezia, and no further hospitalizations during clinic follow-up. She later delivered a healthy baby weighing 6.6 pounds at term. This report shows that despite its use as a third anti-tumor necrosis factor agent in ulcerative colitis, golimumab provided steroid-free clinical remission to a patient who was undergoing a severe flare during her pregnancy. It is one of the early case reports showing the use of golimumab (FDA pregnancy category B) in a pregnant patient with ulcerative colitis. It also shows that despite an ultrasound showing intrauterine growth restriction prior to starting this medication, the patient was able to deliver a full term, healthy baby. Disclosure - Nisha Patel, MD - none. Julie Weatherly, NP - none. Bincy Abraham, MD - consultant & Speakers Bureau: Janssen, UCB, Abbvie, Prometheus, Takeda; Speakers Bureau: Salix; Consultant: Shire.

Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis.

Acute upper gastrointestinal haemorrhage remains the most common medical emergency managed by gastroenterologists. Causes of upper gastrointestinal bleeding (UGIB) in patients with liver cirrhosis can be grouped into two categories: the first includes lesions that arise by virtue of portal hypertension, namely gastroesophageal varices and portal hypertensive gastropathy; and the second includes lesions seen in the general population (peptic ulcer, erosive gastritis, reflux esophagitis, Mallory-Weiss syndrome, tumors, etc.). Emergency upper gastrointestinal endoscopy is the standard procedure recommended for both diagnosis and treatment of UGIB. The endoscopic treatment of choice for esophageal variceal bleeding is band ligation of varices. Bleeding from gastric varices is treated by injection with cyanoacrylate. Treatment with vasoactive drugs as well as antibiotic treatment is started before or at the same time as endoscopy. Bleeding from portal hypertensive gastropathy is less frequent, usually chronic and treatment options include β-blocker therapy, injection therapy and interventional radiology. The standard of care of UGIB in patients with cirrhosis includes careful resuscitation, preferably in an intensive care setting, medical and endoscopic therapy, early consideration for placement of transjugular intrahepatic portosystemic shunt and, sometimes, surgical therapy or hepatic transplant.

OC-011 Is Coffee Ground Vomiting Important? Findings From A Large Bleeding Unit Database With Outcomes At 30 Days

IntroductionUpper gastrointestinal bleeding (UGIB) is a common reason for admission and “coffee ground vomiting” (CGV) has classically been considered a sign but clinical experience hasn’t always borne this out. There...

PTU-029 The Use Of Endoclot™ Therapy In The Endoscopic Management Of Gastrointestinal Bleeding

IntroductionEndoclot™ is a non-toxic topical haemostatic powder consisting of absorbable modified polymers. We previously described our early experience using Endoclot™ as an adjunct haemostatic endoscopic therapy in 6 patients undergoing...

Characterization of the syndrome of UGI bleeding from a Mallory-Weiss tear associated with transesophageal echocardiography.

To quantitatively describe the syndrome of Mallory-Weiss tears associated (MWa) with antecedent transesophageal echocardiography (TEE) as a distinct syndrome. Cases of MWa were identified by comprehensive, computerized literature search via PubMed and review of textbooks and monographs on TEE and gastroenterology. Statistical comparison of 17 identified MWa cases versus previously published series of 73 cases of Mallory-Weiss tears unassociated with TEE (MWu) was performed. A new illustrative case is also currently reported. Comparison between these two groups revealed the following: MWa patients were significantly older (67.1 vs. 52.6 years, p = .0002, assuming equal variance), likely due to MWa patients having preexisting cardiovascular disease for which the TEE was indicated. The two groups had similar sex distributions (60 vs. 76% male, p = .32). MWa patients were significantly, more frequently anticoagulated at the time of bleeding (90.9 vs. 9.6%, p < .00001, OR = 94.3, 95%-OR CI: 9.56-2293), likely because of anticoagulation for underlying cardiac disease for which TEE was indicated. MWa patients tended to more frequently rebleed and more frequently require endoscopic therapy (both parameters: 4/17 vs. 8/73, p = .23) and tended to more frequently require surgery or angiography to control bleeding (3/17 vs. 3/73, p = .08). MWa patients had significantly higher mortality (23.5 vs. 2.7%, p = .01, OR = 10.9, 95%-OR CI 1.48-97.8), likely because of their older age, concomitant heart disease, and administered anticoagulation. A new case of MWa is reported with notable features that extend the clinical spectrum of this syndrome: (1) tear associated with hiatal hernia, (2) presentation with severe, fatal UGI bleeding, and (3) no anticoagulation during bleeding episode. Patients with MWa represent a distinct clinical subset from patients with MWu, with significantly older mean age, more frequent concomitant anticoagulation, and higher mortality. They also tend to have more severe bleeding. These characteristics are important in clinically managing this syndrome.

Sa1540 Spirus Enteroscopy Using Capsule Location Index for Achieving High Diagnostic and Therapeutic Yield

Sa1540 Spirus Enteroscopy Using Capsule Location Index for Achieving High Diagnostic and Therapeutic Yield Rohan H. Mandaliya*, Jason Korenblit, Brendan O’Hare, Anastasia Shnitser, Ramu Kedika, Rebecca Matro, Dina Halegoua, Anthony Infantolino, Mitchell Conn Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA; Internal Medicine, Abington Memorial Hospital, Abington, PA Background: SE (Spirus Enteroscopy) is a new small bowel endoscopic technique which allows deep intubation of the small bowel. Our institution has one of the largest experiences with this technique. Aim: To review the diagnostic and therapeutic yield, and safety of SE; and the predictive role of prior CE (Capsule Endoscopy) at a large academic center. Methods: A retrospective review of patients undergoing SE after prior CE between 2008-2013 was performed. A capsule location index (CLI) was defined as the fraction of total small bowel transit time when the lesion was found on CE. Statistical analysis was performed using Chi-Square and Fisher’s test. Results: A total of 174 SE were available for analysis, antegrade (147) and retrograde (27). Mean age of patients was 66 years. 94(54%) were men and 81(46%) were women. Indications of SE included obscure GI bleeding (141, 81%), diarrhea (11), abdominal pain (13), small bowel obstruction (5), and 1 each for retained foreign body and endocapsule, FAP and Puetz Jeghers syndrome. Abnormalities on SE were detected in 61% of the patients. The most common findings were vascular ectasias (VE) (60, 34%). Abnormalities were located in jejunum (55%), ileum (26%) and duodenum (19%). Therapy was performed in (110, 63%) patients, including APC (66), biopsy (53), endoclip (20), polypectomy (7), dilatation of stricture (2) and retrieval of an endocapsule (1). Procedure was safe in patients who had prior gastric roux-en-Y bypass (nZ6) and entero-enteral anastomosis (nZ5). Procedure related trauma occurred in 4 patients, esophageal mucosal tear with successful placement of clip (3) and a transient intusucception (1). 137 (79%) had prior capsule studies available to review. 131 were positive and 6 were negative. Of the 131 positive CE, corresponding lesions were detected by SE in 81 patients, with a yield of 62%. 115 of 131 positive capsule studies were complete to calculate CLI. Positive antegrade SE had a mean CLI of 0.22 (range 0.0-0.76) compared to 0.40 (range 0.0-0.86) for negative antegrade SE. There was a significant difference in the diagnostic yield with CLI cut off of 0.30 (81%(57/70) when CLI!0.30 vs. 35%(18/51) when CLIOZ0.30, p!0.0001). Mean CLI was 0.88 for positive retrograde SE and 0.76 negative retrograde SE. The best CLI cut off was 0.84 with the diagnostic yield of 75%(6/8) when CLIOZ0.84 vs. 25%(2/8) when CLI!0.84, pZ0.06. A CLI range of 0.60-0.75 had the lowest yield (15%, 2/13) by either approaches. (9 antegrade and 4 retrograde) VE seen on CE was detected in 83% patients on SE; highest yield compared to other findings, p!0.01. Conclusions: 1. Spirus enteroscopy is safe with a high diagnostic and therapeutic yield. 2. CLI is predictive of the success of SE and determines the best route of SE. 3. Lesions with a location index in the range of 0.600.75 have the least likelihood of detection by either approach. Findings on Spirus Enteroscopy Findings on Spirus Enteroscopy www.giejournal.org Number of Patients (n) VE (Vascular Ectasia) nZ60

Bleeding Following Rattlesnake Envenomation in Patients With Preenvenomation Use of Antiplatelet or Anticoagulant Medications

Rattlesnake envenomations commonly produce coagulopathy and thrombocytopenia, yet clinically significant bleeding is uncommon. It is unknown if patients who use antiplatelet or anticoagulant medications prior to envenomation are at increased risk for bleeding after envenomation. This was a retrospective cohort study of patients age 14 years and older who were admitted to a single academic medical center for rattlesnake envenomation. Patients who reported use of antiplatelet or anticoagulant medications prior to envenomation were compared to patients not on those medications. Severity and timing of bleeding was compared between groups, as was a composite endpoint of major bleeding at any time, shock, readmission, or death. A total of 319 patients met inclusion criteria; 31 (9.7%) were documented to be taking antiplatelet or anticoagulant medications including aspirin, clopidogrel, and/or warfarin. Seventeen of the 319 patients developed bleeding associated with envenomation (major = 9; minor = 4; trivial = 4), with major bleeding occurring in five patients on antiplatelet or anticoagulant medications versus four patients not on antiplatelet or anticoagulant medications (p < 0.001). Seven of the 17 presented with early bleeding. This early bleeding occurred in three of 31 (9.7%) patients on antiplatelet or anticoagulant medications and four of 288 (1.4%) patients not on antiplatelet or anticoagulant medications (relative risk [RR] = 6.9; 95% confidence interval [CI] = 1.6 to 29.4; p = 0.022). Clinical outcome data were available for 300 of the 319 (94%) subjects following discharge. Late bleeding (bleeding after discharge from the index hospitalization) occurred in nine subjects, one of whom also had early bleeding (major = 2, minor = 3, trivial = 4). Three of these nine subjects with late bleeding were on antiplatelet or anticoagulant medications, compared with six not on antiplatelet or anticoagulant medications (p = 0.042). Both cases of late major bleeding occurred in patients on antiplatelet or anticoagulant medications. Therefore, among patients with follow-up data available, the overall rate of bleeding (early and late) was seven of 28 (25%) in patients taking antiplatelet or anticoagulant medications and 10 of 273 (3.7%) in patients not taking antiplatelet or anticoagulant medications (p < 0.001). The use of antiplatelet or anticoagulant medications was also associated with an increased risk of reaching the composite endpoint of major bleeding, shock, readmission, or death (6 of 31, or 19.4% vs. 14 of 288, or 4.9%; RR = 3.98; 95% CI = 1.65 to 9.62; p = 0.008). The risk of developing bleeding following rattlesnake envenomation is increased in patients who use antiplatelet or anticoagulant medications. This risk is greatest early after envenomation during the index hospitalization. However, risk of late, major bleeding appears also to be greatest in patients on antiplatelet or anticoagulant medications. Extra vigilance should be taken in patients on antiplatelet or anticoagulant medications and a careful risk/benefit analysis should be undertaken before continuing these medications in the weeks following the envenomation.

Hyperemesis gravidarum: A case of starvation and altered sensorium gestosis (ASG)

Of the problems that complicate child-bearing, hyperemesis gravidarum (HG), or severe nausea and vomiting of pregnancy (NVP), is likely one of the most painful with unrelenting retching and vomiting that can lead to measurable injuries such as Mallory–Weiss Syndrome and esophageal rupture, and/or subtle maternal cognitive impairments related to starvation and dehydration. Recognized hallmarks of HG include dehydration, ketonuria, weight loss over 5%, and electrolyte abnormalities not attributable to other causes.Historically providers regarded the hyperemetic as a difficult to treat patient with potentially underlying psychological problems. Sick patients who experience pain and suffering present challenges to care, not excepting NVP. Ill patients can be demanding and agitated. Agitation can be one of the early signs of delirium or altered mental status (AMS). AMS can include previously diagnosed psychiatric conditions as well as new onset of Wernicke’s encephalopathy, deliria, insomnia, hallucinations and autoscopy, resulting from various etiologies including and not limited to medications, pain including pain from hunger, vomiting and retching, constipation, dehydration, altered electrolytes, hypoglycemia, malnutrition and sleep deprivation.AMS may have a subtle waxing and waning trajectory, making the condition difficult to diagnosis in early stages. What have not been well elucidated in AMS are subjective images and/or experiences. Whether all AMS experiences are similar is unknown. We believe there may be a transient alteration of cognitive status or “altered sensorium gestosis” (ASG), attributed to the direct insults of hyperemesis gravidarum which will be discussed herein. How prevalent ASG might be is unknown and needs further investigation.

Mortality in high-risk patients with bleeding Mallory–Weiss syndrome is similar to that of peptic ulcer bleeding. Results of a prospective database study

Objective. The aim of this study was to identify the predictive factors influencing mortality in patients with bleeding Mallory–Weiss syndrome in comparison with peptic ulcer bleeding. Material and methods.Between January 2005 and December 2009, 281 patients with endoscopically confirmed Mallory–Weiss syndrome and 1530 patients with peptic ulcer bleeding were consecutively evaluated. The 30-day mortality and clinical outcome were related to the patients' demographic data, endoscopic, and clinical characteristics. Results. The one-year cumulative incidence for bleeding Mallory–Weiss syndrome was 7.3 cases/100,000 people and for peptic ulcer bleeding 40.4 cases/100,000 people. The age-standardized incidence for both bleeding Mallory–Weiss syndrome and peptic ulcer bleeding remained unchanged during the observational five-year period. The majority of patients with bleeding Mallory–Weiss syndrome were male patients with significant overall comorbidities (ASA class 3–4). Overall 30-day mortality rate was 5.3% for patients with bleeding Mallory–Weiss syndrome and 4.6% for patients with peptic ulcer bleeding (p = 0.578). In both patients with bleeding Mallory–Weiss syndrome and peptic ulcer bleeding, mortality was significantly higher in patients over 65 years of age and those with significant overall comorbidities (ASA class 3–4). Conclusion. The incidence of bleeding Mallory–Weiss syndrome and peptic ulcer bleeding has not changed over a five-year observational period. The overall 30-day mortality was almost equal for both bleeding Mallory–Weiss syndrome and peptic ulcer bleeding and was positively correlated to older age and underlying comorbid illnesses.

Phase II trial of temozolomide and veliparib combination therapy for sorafenib-refractory advanced hepatocellular carcinoma (HCC).

240 Background: The combination of the imidazotetrazine derivative temozolomide (TMZ) and poly(ADP-ribose) polymerase inhibitor veliparib (ABT-888) has shown in vivo activity against a variety of tumor types through the alkylating effects of TMZ and DNA repair inhibition by ABT-888. To date, no studies have examined the combination of TMZ and ABT-888 in treating advanced HCC refractory to sorafenib. Methods: This is a single arm Phase II trial. Eligible HCC patients have Child Pugh A/B cirrhosis and have failed prior treatment with sorafenib either through intolerance or disease progression. All patients have received ABT-888 40 mg daily on days 1-7 and Temozolomide 150 mg/m2 daily on days 1-5 in 28 day cycles for a maximum of 6 cycles. Tumor response is analyzed every 2 cycles using RECIST criteria. The primary endpoint is time to disease progression. The trial is being conducted using a modified Simon’s two-stage design optimal design as implemented by Hanfelt, et al. Results: The trial is currently in Simon Stage 1 with 16 patients recruited: 9 patients have stopped the study due to disease progression, 3 patients are still on protocol, and 4 patients stopped the study for reasons other than disease progression. 7 patients had disease progression at two months, 1 patient had cancer progression at 4 months, and 1 patient had disease progression at 16 months. Median time to progression in these 9 patients was 56 days (range 42-486 days). The four patients that stopped the study prematurely were for the following reasons: hiccups/dehydration, Mallory-Weiss tear secondary to refractory nausea, intraperitoneal bleeding from exophytic HCC lesion, and development of hepatorenal syndrome in a paracentesis-dependent patient. The most common grade 3 toxicities in this cohort so far have been nausea/vomiting (in 2 subjects), and anemia/thrombocytopenia (in 2 subjects). Defects in DNA repair pathways are being tested from the liver biopsy in the patient who had response to TMZ and ABT-888 for 16 months. Conclusions: The combination of TMZ and ABT-888 is fairly tolerated in patients with advanced HCC. So far, the treatment did not show activities in majority of patients with advanced HCC. Clinical trial information: NCT01205828.

Thoracoscopic removal of dental prosthesis impacted in the upper thoracic esophagus

Dental appliances are the most common cause of accidental foreign body esophageal impaction, especially in the elderly population with decreased oral sensory perception. A 47-year-old man with history of oligophrenia and recurrent epileptic seizures was referred to our hospital following dislocation and ingestion of his upper dental prosthesis. Endoscopic removal and clipping of an esophageal tear had been unsuccessfully attempted. A chest CT scan confirmed entrapment of the dental prosthesis in the upper thoracic esophagus, the presence of pneumomediastinum, and the close proximity of one of the metal clasps of the prosthesis to the left subclavian artery. A video-assisted right thoracoscopy in the left lateral decubitus position was performed and the foreign body was successfully removed. The patient was then allowed to wear the retrieved prosthesis after dentistry consultation and repair of the wire clasps by a dental technician. At the 6-month follow-up visit the patient was doing very well without any trouble in swallowing.