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Evaluation and Management of Mallory – Weiss Syndrome: A Review
Abstract
Upper gastrointestinal bleeding is a symptom of Mallory-Weiss syndrome, which is caused by longitudinal mucosal lacerations (known as Mallory-Weiss tears) near the gastroesophageal junction or gastric cardia. Mallory-Weiss syndrome is rather prevalent, accounting for 3 to 10% of all upper gastrointestinal bleeding episodes. In mild circumstances, the disease may be asymptomatic. Hematemesis is the presenting symptom in 85 percent of patients. Blood is present in varying amounts, ranging from blood-streaked mucous to huge bright red haemorrhage. Other symptoms such as melena, dizziness, or syncope might occur as a result of heavy bleeding. The majority of the time, the bleeding is little and ends on its own. Endoscopy is frequently used to confirm the diagnosis of MWS. Although most patients may be treated with monitoring or conservative medicinal treatment, certain cases require endoscopic or surgical treatment. Despite the fact that MWS is a common cause of nonvariceal upper gastrointestinal bleeding (NVUGIB), little research has been done on it. This article discusses MWS Etiology, epidemiology, evaluation and management.
... Highest incidence is seen in men, especially in the age group of 40 to 60 years. It is usually manifested as hematemesis and melena, and the diagnosis is confirmed with endoscopy [18,19]. It often heals spontaneously within 48-72 hours after arresting the bleed. ...
Introduction: Primary Percutaneous Coronary Intervention (PPCI) with stenting, especially with Drug eluting stents (DES), is the most widely accepted strategy globally for patients presented with STEMI, which necessitates a long duration of Dual antiplatelet therapy (DAPT) to prevent stent thrombosis. Potent P2Y12 inhibitors for DAPT are preferred in view of their superior protection against thrombosis but at the expense of increased bleeding risks. Early therapeutic intervention in the event of acute GI bleed has beneficial outcome while on active cardiac intervention.
Case Presentation: A 67-year-old patient, who underwent PPCI with DES stent, incidentally developed Mallory-Weiss (MW) tear, which manifested as severe hematemesis when loaded with DAPT consisting of Aspirin and Ticagrelor. The therapy was withheld until the clipping of the tear was done. Single antiplatelet therapy (SAPT) with Aspirin was reinstituted after a day and DAPT with Aspirin plus Clopidogrel after a week.
Conclusion: A careful assessment of the risks and benefits of acute coronary interventions need to consider complications and timely interventions thus individualizing and curating the DAPT as deemed necessary.
... Highest incidence is seen in men, especially in the age group of 40 to 60 years. It is usually manifested as hematemesis and melena, and the diagnosis is confirmed with endoscopy [18,19]. It often heals spontaneously within 48-72 hours after arresting the bleed. ...
Introduction: Primary Percutaneous Coronary Intervention (PPCI) with stenting, especially with Drug eluting stents (DES), is the most widely accepted strategy globally for patients presented with STEMI, which necessitates a long duration of Dual antiplatelet therapy (DAPT) to prevent stent thrombosis. Potent P2Y12 inhibitors for DAPT are preferred in view of their superior protection against thrombosis but at the expense of increased bleeding risks. Early therapeutic intervention in the event of acute GI bleed has beneficial outcome while on active cardiac intervention. Case Presentation: A 67-year-old patient, who underwent PPCI with DES stent, incidentally developed Mallory-Weiss (MW) tear, which manifested as severe hematemesis when loaded with DAPT consisting of Aspirin and Ticagrelor. The therapy was withheld until the clipping of the tear was done. Single antiplatelet therapy (SAPT) with Aspirin was reinstituted after a day and DAPT with Aspirin plus Clopidogrel after a week. Conclusion: A careful assessment of the risks and benefits of acute coronary interventions need to consider complications and timely interventions thus individualizing and curating the DAPT as deemed necessary.
Gastrointestinal (GI) bleeding is a critical and potentially life-threatening condition frequently observed in the intensive care unit (ICU). This literature review consolidates current insights on the epidemiology, etiology, management, and outcomes of GI bleeding in critically ill patients. GI bleeding remains a significant concern, especially among patients with underlying risk factors such as coagulopathy, mechanical ventilation, and renal failure. Managing GI bleeding in the ICU requires a multidisciplinary approach, including resuscitation, endoscopic intervention, pharmacologic therapy, and sometimes surgical procedures. Even with enhanced management strategies, GI bleeding in the ICU is associated with considerable morbidity and mortality, particularly when complicated by multi-organ failure. This review reiterates the need for adequate resuscitation and interventions in managing GI bleeding in critically ill patients, aiming to enhance survival rates and improve the quality of care within the ICU setting.
Background:
Adverse events during endoscopic submucosal dissection (ESD) of superficial esophageal neoplasms, such as perforation and bleeding, have been well-documented. However, the Mallory-Weiss Tear (MWT) during esophageal ESD remains under investigation.
Aim:
To investigate the incidence and risk factors of the MWT during esophageal ESD.
Methods:
From June 2014 to July 2017, patients with superficial esophageal neoplasms who received ESD in our institution were retrospectively analyzed. The clinicopathological characteristics of the patients were collected. Patients were divided into an MWT group and non-MWT group based on whether MWT occurred during ESD. The incidence of MWTs was determined, and the risk factors for MWT were then further explored.
Results:
A total of 337 patients with 373 lesions treated by ESD were analyzed. Twenty patients developed MWTs during ESD (5.4%). Multivariate analysis identified that female sex (OR = 5.36, 95%CI: 1.47-19.50, P = 0.011) and procedure time longer than 88.5 min (OR = 3.953, 95%CI: 1.497-10.417, P = 0.005) were independent risk factors for an MWT during ESD. The cutoff value of the procedure time for an MWT was 88.5 min (sensitivity, 65.0%; specificity, 70.8%). Seven of the MWT patients received endoscopic hemostasis. All patients recovered satisfactorily without surgery for the laceration.
Conclusion:
The incidence of MWTs during esophageal ESD was much higher than expected. Although most cases have a benign course, fatal conditions may occur. We recommend inspection of the stomach during and after the ESD procedure for timely management in cases of bleeding MWTs or even perforation outside of the procedure region.
Mallory-Weiss syndrome (MWS) is a relatively less common cause of nonvariceal upper gastrointestinal bleeding. There is limited data on whether scoring systems could be used to predict the clinical outcomes in patients with bleeding due to MWS. The aim of our study is to evaluate whether the Glasgow-Blatchford score (GBS), AIMS65, and shocking index are effective in predicting the clinical outcomes of MWS.
One hundred twenty-eight patients from January 2010 to January 2017 with MWS in middle China were enrolled. Clinical features such as age, gender, causes of vomiting, endoscopic findings, GBS, AIMS65, and shocking index were recorded. The clinical outcomes including endoscopic treatment and transfusion were analyzed.
MWS accounted for 6.1% of nonvariceal upper gastrointestinal bleeding. Male-to-female ratio was 3.6:1 and median age was 51 years. Patients between 40 and 60 years were more commonly affected; 43.8% of MWS was caused by overdrinking followed by underlying gastric diseases (33.6%). However, for female patients alone, underlying gastric diseases were the leading cause (42.9%). The tears were usually single and most frequently located on the left lateral wall. In receiver-operating characteristic curve analyses, GBS system and shocking index were useful in predicting transfusion (0.856 vs 0.675). But for endoscopic intervention, these scoring systems are not helpful (P > .05).
Apart from drinking, underlying gastric disease is another important cause of MWS especially for female patients and should be paid more attention under endoscopy examination. GBS system and shocking index can be used to predict transfusion.
Mallory-Weiss tearing (MWT) is a common cause of non-variceal upper gastrointestinal bleeding. Although the majority of patients with bleeding MWT require no intervention other than hemodynamic supports, spectrum of MWT is wide, and the condition sometimes results in a fatal outcome. Endoscopic management to stop the bleeding may be required during the index endoscopy, especially in those with active bleeding or stigmata of recurrent bleeding. Most commonly used endoscopic treatment for actively bleeding MWT is injection therapy, argon plasma coagulation, hemoclip placement, and band ligation. Selection of the optimal endoscopic hemostasis depends on the physician's ability and patient's clinical status.
Inequalities in health are well recognized in cardiovascular disease and cancer, but in comparison, we have minimal understanding for upper gastrointestinal bleeding. Since furthering our understanding of such inequality signposts preventable disease, we investigated in detail the association between upper gastrointestinal bleeding and socioeconomic status.
Population-based cohort study.
All English National Health Service hospitals.
English adult population, 1 January 2001 to 31 December 2007. EXPOSURE MEASURES: Deprivation scores defined according to quintiles of neighbourhood areas ranked by the Indices of Multiple Deprivation for England 2007.
Rates of all adult admissions coded with a primary diagnosis of upper gastrointestinal bleed were analysed by deprivation quintile and adjusted for age, sex, region and year using Poisson regression.
The annual hospitalization rate for non-variceal haemorrhage was 84.6 per 100,000 population (95% CI 83.5 to 84.1; n=237,145), and for variceal haemorrhage, it was 2.83 per 100,000 population (95% CI 2.87 to 2.99; n=8291). There was a twofold increase in the hospitalization rate ratio for non-variceal haemorrhage from the most deprived areas compared to the least deprived (2.00, 95% CI 1.98 to 2.03). The ratio for variceal haemorrhage was even more pronounced (2.49, 95% CI 2.32 to 2.67). Inequality increased over the study period (non-variceal p<0.0001, variceal p=0.0068), and adjusting for age and sex increased the disparity between deprived and affluent areas. Case fatality did not have a similar socioeconomic gradient.
Both variceal and non-variceal haemorrhage hospitalization rates increased with deprivation, and there was a similar gradient in all areas of the country and in all age bands. The existence of such a steep gradient suggests that there are opportunities to reduce hospitalizations down to the low rates seen in the most affluent, and thus, there is the potential to prevent almost 10,000 admissions and over 1000 deaths a year.
The aim of this study was to establish the relative importance of risk factors for mortality after acute upper gastrointestinal haemorrhage, and to formulate a simple numerical scoring system that categorizes patients by risk. A prospective, unselected, multicentre, population based study was undertaken using standardised questionnaires in two phases one year apart. A total of 4185 cases of acute upper gastrointestinal haemorrhage over the age of 16 identified over a four month period in 1993 and 1625 cases identified subsequently over a three month period in 1994 were included in the study. It was found that age, shock, comorbidity, diagnosis, major stigmata of recent haemorrhage, and rebleeding are all independent predictors of mortality when assessed using multiple logistic regression. A numerical score using these parameters has been developed that closely follows the predictions generated by logistical regression equations. Haemoglobin, sex, presentation (other than shock), and drug therapy (non-steroidal anti-inflammatory drugs and anticoagulants) are not represented in the final model. When tested for general applicability in a second population, the scoring system was found to reproducibly predict mortality in each risk category. In conclusion, a simple numerical score can be used to categorize patients presenting with acute upper gastrointestinal haemorrhage by risk of death. This score can be used to determine case mix when comparing outcomes in audit and research and to calculate risk standardised mortality. In addition, this risk score can identify 15% of all cases with acute upper gastrointestinal haemorrhage at the time of presentation and 26% of cases after endoscopy who are at low risk of rebleeding and negligible risk of death and who might therefore be considered for early discharge or outpatient treatment with consequent resource savings.
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).
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).
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.
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.
Aim:
There is limited data on whether scoring systems can be used to predict clinical outcomes in patients with upper gastrointestinal bleeding due to Mallory-Weiss syndrome (MWS). We evaluated whether the Glasgow-Blatchford score (GBS) could be effective in predicting clinical outcomes of bleeding MWS. We also investigated the predictive ability of the Forrest classification for rebleeding and assessed the effective endoscopic modalities for bleeding control in MWS.
Methods:
From January 2004 to December 2012, 168 patients were diagnosed with MWS in Asan Medical Center emergency department. We analyzed their clinical outcomes including endoscopic treatment, transfusion and admission as well as the rates of rebleeding and mortality using GBS and the Forrest classification, retrospectively.
Results:
Endoscopic treatment was applied to 88 patients (52.4%). The GBS was significantly higher in this group than in the conservative treatment group (6.8 ± 3.7 vs. 5.1 ± 4.7, P = .011). In patients with a GBS higher than 6 points, the rates of endoscopic treatment and rebleeding and the need for transfusion and admission were significantly higher (all P <0.05). The Forrest classification was able to predict recurrent bleeding (area under the curve = 0.723, 95% confidence interval, 0.609-0.836, P = 0.025). Hemoclip-based therapy and band ligation achieved higher success rates than did injection therapy alone in preventing rebleeding (96.4%, 88.9%, and 71.4%, P = 0.012).
Conclusions:
In MWS, GBS might be useful for predicting clinical outcomes and the Forrest classification in predicting recurrent bleeding.
Material and methods:
The analysis included 2120 gastroscopy results, with 111 (5.24%) examinations conducted due to symptomatic gastrointestinal bleeding. In the studied group, endoscopic diagnosis of Mallory-Weiss syndrome was made in 22 patients (1.04%).
Results:
The studied disease entity was the cause of upper gastrointestinal bleeding in 19.82% of cases. Although this condition is usually characterised by a mild and self-limiting course, 59.09% of patients in the studied group required therapeutic endoscopic intervention due to active bleeding. In 54.55%, argon plasma coagulation was successfully used to control the source of bleeding.
Conclusions:
Early gastroscopy, which remains both a diagnostic and therapeutic intervention, guarantees effective control of the clinical course of Mallory-Weiss syndrome. Endoscopic argon plasma coagulation is an effective way to treat bleeding, used in endoscopic monotherapy or in combination with other procedures.
Acute non-variceal upper gastrointestinal bleeding (ANVUGIB) is one of the most common medical emergencies in China and worldwide. In 2009, we published the "Guidelines for the diagnosis and treatment of acute non-variceal upper gastrointestinal bleeding" for the patients in China; however, during the past years numerous studies on the diagnosis and treatment of ANVUGIB have been conducted, and the management of ANVUGIB needs to be updated. The guidelines were updated after the databases including PubMed, Embase and CNKI were searched to retrieve the clinical trials on the management of ANVUGIB. The clinical trials were evaluated for high-quality evidence, and the advances in definitions, diagnosis, etiology, severity evaluation, treatment and prognosis of ANVUGIB were carefully reviewed, the recommendations were then proposed. After several rounds of discussions and revisions among the national experts of digestive endoscopy, gastroenterology, radiology and intensive care, the 2015 version of "Guidelines for the diagnosis and treatment of acute non-variceal upper gastrointestinal bleeding" was successfully developed by the Chinese Journal of Internal Medicine, National Medical Journal of China, Chinese Journal of Digestion and Chinese Journal of Digestive Endoscopy. It shall be noted that although much progress has been made, the clinical management of ANVUGIB still needs further improvement and refinement, and high-quality randomized trials are required in the future. © 2016 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.
Background: Effective hemostatic treatment is mandatory for patients with actively bleeding Mallory-Weiss syndrome. This study evaluated the respective efficacy and the safety of endoscopic band ligation and endoscopic epinephrine injection in Mallory-Weiss syndrome. Methods: Thirty-four consecutive patients with actively bleeding Mallory-Weiss syndrome were prospectively enrolled and were randomly assigned to undergo endoscopic band ligation or endoscopic injections of a 1:10,000 solution of epinephrine. Demographic characteristics, endoscopic variables, and outcome parameters, including rates of hemostasis and recurrent bleeding, were analyzed. Results: The number of elastic bands applied was one or two; the mean volume of epinephrine injected was 18.0 mL: 95% CI[16.8, 19.2]. There was no significant difference between the groups with respect to age, gender, alcohol ingestion, presenting symptoms, Hb level, shock, comorbid diseases, coagulopathy, tear location, blood transfusion, or duration of hospitalization. Primary hemostasis was achieved in all 17 patients in the band ligation group and in 16 of 17 patients (94.1%) in the epinephrine injection group. There was no recurrence of bleeding or major complication in either group. Conclusions: In this small study, no difference was detected in the efficacy or the safety of band ligation vs. epinephrine injection for the treatment of actively bleeding Mallory-Weiss syndrome.
Aim
To quantitatively describe the syndrome of Mallory-Weiss tears associated (MWa) with antecedent transesophageal echocardiography (TEE) as a distinct syndrome.
Methods
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.
Results
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
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.
Goals:
To evaluate sources of upper gastrointestinal bleeding (UGIB) at an urban US hospital and compare them to sources at the same center 20 years ago, and to assess clinical outcomes related to source of UGIB.
Background:
Recent studies suggest changes in causes and outcomes of UGIB.
Study:
Consecutive patients with hematemesis, melena, and/or hematochezia undergoing upper endoscopy with an identified source at LA County+USC Medical Center from January 2005 to June 2011 were identified retrospectively.
Results:
Mean age of the 1929 patients was 52 years; 75% were male. A total of 1073 (55%) presented with hematemesis, 809 (42%) with melena alone, and 47 (2%) with hematochezia alone. The most common causes were ulcers in 654 patients (34%), varices in 633 (33%), and erosive esophagitis in 156 (8%), compared with 43%, 33%, and 2% in 1991. During hospitalization, 207 (10.7%) patients required repeat endoscopy for UGIB (10.6% for both ulcers and varices) and 129 (6.7%) died (5.2% for ulcers; 9.2% for varices). On multivariate analysis, hematemesis (OR=1.38; 95% CI, 1.04-1.88) and having insurance (OR=1.44; 95% CI, 1.07-1.94) were associated with repeat endoscopy for UGIB. Varices (OR=1.53; 95% CI, 1.05-2.22) and having insurance (OR=4.53; 95% CI, 2.84-7.24) were associated with mortality.
Conclusion:
Peptic ulcers decreased modestly over 2 decades, whereas varices continue as a common cause of UGIB at an urban hospital serving lower socioeconomic patients. Inpatient mortality, but not rebleeding requiring endoscopy, was higher with variceal than nonvariceal UGIB, indicating patients with variceal UGIB remain at risk of death from decompensation of underlying illness even after successful control of bleeding.
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.
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.
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.
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.
Mallory-Weiss syndrome is relatively common and is involved in 3 to 10% of cases of upper gastrointestinal bleeding. Most of the time, the hemorrhage is mild and stops spontaneously. Clinical suspicion requires confirmation by an upper gastrointestinal endoscopy, which must be performed rapidly after the first hematemesis. Mallory-Weiss syndrome is diagnosed when it shows a longitudinal mucosal tear at the esophagogastric junction. Patients with active bleeding or signs of recent bleeding at endoscopy need immediate endoscopic treatment for hemostasis. Band ligation seems to be the most efficient procedure for primary hemostasis and for preventing recurrent bleeding. The use of proton pump inhibitors and antiemetics seems logical in all cases, although nothing in the literature demonstrates their efficacy.
Copyright 2009 Elsevier Masson SAS. All rights reserved.
With the increasing early use of endoscopy, Mallory-Weiss syndrome has been found to be the cause of upper gastrointestinal bleeding in 224 of 2,175 (10.3 percent) patients studied. Since Mallory-Weiss syndrome is a self-limiting disease in more than 90 percent of patients, conservative treatment, including multiple transfusion, electrocoagulation, and compression by a Sengstaken-Blakemore tube in descending order of use, is the treatment of choice, especially in the medically debilitated patient. The cirrhotic patient poses special difficulty and generally has a poor outcome no matter what the treatment. Prolapse of the stomach into the esophagus may be an etiologic factor in a small subgroup of patients.
Although they account for a minority of episodes of upper gastrointestinal bleeding, the awareness of less frequent causes of upper gastrointestinal bleeding can be crucial to the endoscopist in the evaluation of the patient with bleeding. This review discusses the Dieulafoy lesion, hemobilia, gastric antral vascular ectasia, Mallory-Weiss tear, and gastroduodenal arteriovenous malformation.
Although patients with bleeding Mallory-Weiss tears are generally hospitalized, we wished to develop guidelines facilitating the selection, by clinical and endoscopic criteria, of patients who do not need hospitalization. Our specific aims were to determine whether presenting manifestations of bleeding differed in hemodynamically unstable patients, whether active bleeding or stigmata of bleeding at endoscopy were prognosticators for significant rebleeding, and the outcomes in endoscopically managed patients.
The endoscopic and clinical features of all patients with acute GI bleeding from a Mallory-Weiss tear were obtained from our GI Bleeding Team database over a consecutive 4-yr period and analyzed for prognostic indicators.
1) Presenting manifestations, e.g., hematochezia, were significantly different in hypotensive patients. 2) Active bleeding but not stigmata was associated with higher transfusion requirements. 3) Rebleeding was unusual, occurring within 24 h, more often in patients with a bleeding/coagulation diathesis. The median hospital stay was 4 days (range 1-24). Fifty-seven percent of patients received transfusion (median 4 units, range 1-26 units); requirements were higher in patients with coagulopathies.
Patients without risk factors for rebleeding (portal hypertension, coagulopathy), clinical features indicating severe bleeding (hematochezia, hemodynamic instability), or active bleeding at endoscopy can be managed with a brief period of observation. Patients with endoscopically active bleeding may benefit from endoscopic therapy.
Current risk-stratification systems for patients with acute upper-gastrointestinal bleeding discriminate between patients at high or low risks of dying or rebleeding. We therefore developed and prospectively validated a risk score to identify a patient's need for treatment.
Our first study used data from 1748 patients admitted for upper-gastrointestinal haemorrhage. By logistic regression, we derived a risk score that predicts patients' risks of needing blood transfusion or intervention to control bleeding, rebleeding, or dying. From this score, we developed a simplified fast-track screen for use at initial presentation. In a second study, we prospectively validated this score using receiver operating characteristic (ROC) curves--a measure of the validity of a scoring system--and chi2 goodness-of-fit testing with data from 197 patients. We also validated the quicker screening tool.
We calculated risk scores from patients' admission haemoglobin, blood urea, pulse, and systolic blood pressure, as well as presentation with syncope or melaena, and evidence of hepatic disease or cardiac failure. The score discriminated well with a ROC curve area of 0.92 (95% CI 0.88-0.95). The score was well calibrated for patients needing treatment (p=0.84).
Our score identified patients at low or high risk of needing treatment to manage their bleeding. This score should assist the clinical management of patients presenting with upper-gastrointestinal haemorrhage, but requires external validation.
The endoscopic hemostatic method has been introduced as a safe and effective mechanical approach to hemostasis for upper gastrointestinal bleeding related to Mallory-Weiss syndrome (MWS). However, the indications for when to use endoscopic treatment are debatable because many patients need only medical observation. The study was designed to evaluate the necessity and efficacy of endoscopic hemostasis in upper gastrointestinal bleeding related to MWS.
From July 1994 to May 2000, we conducted a clinical trial in 76 patients who were found by endoscopy to have active bleeding (I, spurting; II, oozing), protruding visible vessels (III), and/or adherent clots (IV). Two study periods can be differentiated: in the first 3 years endoscopic treatment (n = 30) was prospectively analyzed and in the final 3 years medical treatment (n = 46) was analyzed in both cases to compare the outcome in MWS bleeding II-IV. In the first study period, in addition, endoscopic treatment was randomised to an injection method, using a mixture of hypertonic saline and epinephrine (HSE) (n = 14) and a hemoclipping or band ligation method (n = 16).
Rebleeding was observed in four of 14 patients who had received endoscopic hemostasis with HSE injection and one of 46 patients who had been managed with medical treatment. No rebleeding was found following hemoclipping or band ligation. While all rebleeding was in bleeding stigmata of the I (1) and II (4) grades, there was no rebleeding in protruding visible vessels (III) or in adherent clots (IV), regardless of treatment methods.
Our results suggested that endoscopic hemostasis is not necessary in patients without active bleeding stigmata, and the mechanical hemostatic method is more effective than HSE injection in patients with active bleeding stigmata.
Although the majority of patients with Mallory-Weiss syndrome (MWS) have a benign course, MWS patients with recurrent bleeding have an unfavorable outcome and require intensive care. Therefore, this study was carried out to identify the risk factors for recurrent bleeding in MWS patients.
The medical records of patients with MWS between January 1999 and December 2003, were reviewed retrospectively. Demographics, initial clinical and laboratory parameters, and endoscopic findings of the patients with and without recurrent bleeding were compared and the potential risk factors predicting recurrent bleeding in MWS were evaluated.
A total of one hundred and fifty-nine patients (22 women, 137 men, mean age 48.1 years old) were enrolled in the study. Recurrent bleeding was observed in 17 patients (10.7%). Those patients with recurrent bleeding showed higher frequency for the presence of shock at initial manifestation, combined liver cirrhosis and endoscopic findings of active bleeding, lower hemoglobin level and platelet count, higher amount of transfusions and epinephrine-mixed fluid injections, and longer hospital stay than those patients without recurrent bleeding. Significant risk factors predicting the recurrent bleeding in MWS were the presence of shock at initial manifestation (OR 3.71, 95% CI 1.07-14.90) and the evidence of active bleeding on endoscopic examination (OR 9.89, 95% CI 1.88-51.98) on multivariate analysis.
Intensive care with close monitoring is required for the patients with shock on initial manifestation or with evidence of active bleeding on endoscopic examinations since these are independent risk factors predicting the recurrent bleeding in MWS patients.
Weiss Tear Overview of Mallory-Weiss Syndrome. Updated
- Louis Michel Wong Kee Song
- K Praveen
- Roy
Louis Michel Wong Kee Song,Praveen K
Roy, et al. Mallory-Weiss Tear Overview of
Mallory-Weiss Syndrome. Updated;2019.
Medscape.
Available:https://emedicine.medscape.com
/article/187134-overview
Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage. A prospective controlled trial
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