Hemorragia del tracto digestivo superior, enfoque para el médico general / Upper digestive tract bleeding, approach for the general Practitioner / Hemorragia do trato digestivo superior, enfoque para o médico geral

La hemorragia del tracto digestivo superior (HTDS) es el sangrado originado por encima del ángulo de Treitz. A pesar del aumento en las estrategias de prevención, del incremento en los tratamientos con Inhibidor de bomba de protones (IBP) y de la intervención endoscópica temprana, esta patología sigue siendo una causa frecuente de consulta a urgencias, con una morbimortalidad no despreciable y alta carga para el sistema de salud. Esta revisión se enfoca en la HTDS de causa diferente a las varices. La principal causante de esta entidad es la enfermedad ácido-péptica, que es consecuencia del gran consumo de antiinflamatorios no esteroideos (AINES) y de la infección por Helicobacter Pylori. Otras causas son el síndrome de Mallory Weiss, la esofagitis erosiva, las malformaciones arteriovenosas y la malignidad.

Upper gastrointestinal bleeding (UGIB) refers to any bleeding originating above the angle of Treitz. Despite an increase in prevention strategies, proton pump inhibitor (PPI) therapy and early endoscopic intervention, this pathology continues to be an important cause of admission to the emergency department for gastrointestinal causes, having a pretty high morbidity and mortality in addition to a high burden on the health system. This review focuses on non-variceal UGIB. The main cause of this entity being peptic acid disease, due to great consumption of NSAIDs and Helicobacter Pylori infection. Other causes are Mallory Weiss syndrome, erosive esophagitis, arteriovenous malformations, and malignancy.

A hemorragia do trato digestivo superior (HTDS) é o sangrado originado acima do ângulo de Treitz. Apesar do aumento nas estratégias de prevenção, do incremento nos tratamentos com Inibidor da bomba de prótons (IBP) e da intervenção endoscópica precoce, esta patologia segue sendo uma causa frequente de consulta a urgências, com uma morbimortalidade não depreciável e alta carga para o sistema de saúde. Esta revisão se enfoca na HTDS de causa diferente às varizes. A principal causante desta entidade é a doença ácido-péptica, que é consequência do grande consumo de anti-inflamatórios não esteróideos (AINES) e da infecção por HelicobacterPylori. Outras causas são a síndrome de Mallory Weiss, a esofagites erosiva, as malformações arteriovenosas e a malignidade. Palavras-chave: hemorragia gastrointestinal; úlcera péptica; endoscopia gastrointestinal; inibidores da bomba de prótons; medicina geral.

Conducta actual frente la hemorragia digestiva alta: desde el diagnóstico al tratamiento / Current behavior against Upper Digestive Hemorrhage: from diagnosis to treatment

Resumen La hemorragia digestiva alta (HDA) es una emergencia médico-quirúrgica común que debe ser tratada precozmente por su alta morbimortalidad. Corresponde a sangrado del esófago, estómago o del duodeno proximal, y se divide en etiología no variceal y variceal. Dentro de las no variceales destaca la úlcera péptica como la más frecuente, siendo esta producida por un desbalance entre factores protectores y agresivos. Por otro lado, en las hemorragias variceales destacan las várices gastroduodenales, las cuales son consecuencia del aumento de la presión portal. La incidencia de la HDA a nivel mundial varía entre 37 a 172 casos por cada 100.000 habitantes por año y la mortalidad entre un 5 y un 14% según diferentes estudios. Lamentablemente, no existen cifras nacionales fidedignas de incidencia y prevalencia. El médico debe conocer bien la presentación clínica y la fisiopatología para ser asertivo en la sospecha, diagnóstico y manejo de esta patología. En cuanto al tratamiento, el enfrentamiento se divide en el manejo de urgencias y luego endoscópico, puesto que la resucitación temprana intensiva puede reducir la morbimortalidad en pacientes con HDA. A continuación se hará una revisión actualizada enfocada en los aspectos más relevantes del manejo de esta patología. Se obtuvieron los datos de Pubmed y Scielo, específicamente la búsqueda de artículos originales y de revisiones sistemáticas con las palabras "hemorragia digestiva alta", "úlcera péptica", "várices esofágicas" y otras relacionadas. Los criterios usados fueron artículos preferentemente menores a 5 años de publicación en revistas científicas de alto índice de impacto.

Upper gastrointestinal bleeding (UHD) is a common medical-surgical emergency that must be treated early due to its high morbidity and mortality. It corresponds to bleeding from the esophagus, stomach, or proximal duodenum, and is divided into non-variceal and variceal etiology. Among the non-variceal, the peptic ulcer stands out as the most frequent, being this produced by an imbalance between protective and aggressive factors. On the other hand, in variceal hemorrhages gastroduodenal varices stand out, are a consequence of increased portal pressure. The incidence of HDA worldwide varies between 37 to 172 cases per 100,000 inhabitants per year and mortality between 5 to 14% according to different studies. Unfortunately, there are no reliable national statistics of incidence and prevalence. The physician must have a good understanding of the clinical presentation and pathophysiology to be assertive in the suspicion, diagnosis, and management of this pathology. Regarding treatment, the confrontation is divided into emergency management and then endoscopic, because early intensive resuscitation can reduce morbidity and mortality in patients with UHD. This is an updated review which will be focused on the most relevant aspects of the management of this pathology. Data were obtained from Pubmed and Scielo, specifically searching for original articles and systematic reviews with the words "upper gastrointestinal bleeding", "peptic ulcer", "esophageal varices" and other related words. The criteria used were articles preferably less than 5 years old in scientific journals with a high impact index.

Mallory-Weiss Tear After Cardiopulmonary Resuscitation in a Patient Suffering From Acute Myocardial Infarction / 고신대학교의과대학학술지

A report of a 79 year old male patient suffering from acute myocardial infarction with Mallory-Weiss tear after successful cardiopulmonary resuscitation(CPR) by emergency medical technician in the swimming pool is presented. Successful percutaneous coronary intervention(PCI) was done after appropriate transfusion. The patient survived and discharged without major complications after admitting 11days in the hospital. Importance of CPR in AMI patient is reiterated as complication such as Mallory-Weiss tear may arise.

Is the AIMS 65 Score Useful in Prepdicting Clinical Outcomes in Korean Patients with Variceal and Nonvariceal Upper Gastrointestinal Bleeding?

BACKGROUND/AIMS: Various clinical scoring systems, including the Glasgow-Blatchford score (GBS), Rockall risk score (RS), and AIMS65 score (AIMS65), have been validated to predict the clinical outcomes in patients with upper gastrointestinal bleeding (UGIB). We compared the performance of these three scoring systems in predicting clinical outcomes in patients with UGIB in Korea. METHODS: We retrospectively evaluated 286 patients with UGIB who visited emergency department. The primary outcome was the need for clinical intervention (endoscopic, radiologic, or surgical) and blood transfusion. RESULTS: The causes of UGIB were esophageal/gastric varices in 64 patients, peptic ulcer in 168, Mallory-Weiss tear in 32, malignancy of UGI tract in eight, and unknown in 14. One hundred seventy-four (61%) patients required blood transfusion, 166 (58%) required endoscopic intervention, and 10 (3.5%) required surgical intervention. The GBS outperformed the RS and AIMS65 in predicting the need for endoscopic intervention. CONCLUSIONS: The GBS and RS were more accurate than AIMS65 in predicting the need for clinical interventions and transfusion patients with UGIB, regardless of variceal or nonvariceal bleeding. The AIMS65 may not be optimal for predicting clinical outcomes of UGIB in Korea.

Endoscopic Management of Mallory-Weiss Tearing

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.

Observations of Acid Reflux and Motor Function in Distal Esophagus Using Simultaneous Measurements of Intra-esophageal pH and Pressure in 8 Directions With Novel Sensor Catheter: A Feasibility Study

BACKGROUND/AIMS: Esophagogastric junctional lesions, such as mucosal breaks with Los Angeles grade A or B reflux esophagitis, lacerations in Mallory Weiss syndrome, and short segment Barrett's esophagus, are mainly found in the right anterior wall of the distal esophagus. Asymmetrical lower esophageal sphincter pressure and resting radial asymmetrical acid reflux may be causes of this asymmetrical distribution of reflux esophagitis and short segment Barrett's esophagus. We developed a novel pH and pressure catheter to investigate the asymmetrical distributions of pH and intra-esophageal pressure in the distal esophagus. METHODS: One healthy male volunteer was enrolled in this study. Acid reflux and motor function in distal esophagus was investigated using simultaneous measurements of intra-esophageal pH and pressure in 8 directions with novel sensor catheter. RESULTS: Thirty-six acid and weak acid reflux events were observed, of which 22 were circumferential refluxes with pH drops in all channels and 14 were partial refluxes with pH drops in some channels. Increase in transient circumferential intraesophageal pressure was observed just after 72.7% of the circumferential reflux and 42.9% of the partial reflux events. CONCLUSIONS: Using a novel sensor catheter, 2 different types of acid reflux events were identified in the present study.

Life Threatening Upper Gastrointestinal Bleeding in Neonate: A Report of Two Cases

Neonatal upper gastrointestinal bleeding is rare in healthy full term infants and is known to be caused by stress ulcer, intracranial hemorrhage, increased intracranial pressure, congenital heart disease, perinatal asphyxia, respiratory distress, hypoglycemia and use of drugs such as steroids. Mallory-Weiss syndrome and hemorrhagic gastritis can cause life threatening upper gastrointestinal bleeding and are rarely reported in neonates and young infants. The authors experienced a case of Mallory-Weiss syndrome in a full term infant without particular perinatal history and a case of acute hemorrhagic gastritis in a preterm infant born at 33 weeks of gestation and 2,260 g of birth weight, both showed life threatening upper gastrointestinal bleeding. We report these two cases with a review of current literature.

Frequency of esophageal varices in patients with upper gastrointestinal bleeding

To calculate the frequency of esophageal varices in patients with upper gastrointestinal bleeding. It is a cross sectional study. One hundred patients of upper Gl bleeding were included in the study. After initial history and clinical examination, upper Gl endoscopy was performed to assess the cause of bleeding and all the relevant data was entered in the specific proforma designed by authors. One hundred patients [56 male and 44 females] of upper Gl hemorrhage were included. Fifty three patients had esophageal varices while 12 patients had duodenal ulcer, 14 had gastric ulcer, 16 had Gastroduodenal erosions, two patients had erosive esophagitis, one patient had Mallory Weiss tear, one had gastric carcinoma and one had coagulopathy. Esophageal varices are the most common cause of upper Gl bleeding in this area where this study was conducted

Mallory-Weiss Syndrome Occurring in a Hanging Patient: Case Report

Reflex gasping when hanging leads to passive and vigorous vomiting, the mechanical force of which causes gastric mucosa laceration. Mallory-Weiss syndrome is a tear in the gastro-esophageal junction or its adjacent mucosa, and this can occur due to nausea or vomiting that is caused by various etiologic factors. Gastric fundus is the most common site of gastric mucosa lacerations. We report a case of a 41-year-old man, who tried to hang himself and, as a result, caused multiple gastric mucosa lacerations that were treated by an endoscopic hemostatic procedure in the emergency room.

The Benefit of Percutaneous Endoscopic Gastrostomy Is Low in Patients with Dementia / 대한소화기내시경학회지

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) is beneficial in treatment of stroke or head and neck cancer. The situation for dementia is unknown. Presently, results, complications, and survival of PEG patients with or without dementia were assessed. METHODS: In a retrospective analysis of 67 patients, gender, age, diagnosis, laboratory results, complications, tube change, early death and death were compared in dementia (n=5) and non-dementia (n=62) patients (average age 68.7 years). RESULTS: Patient clinical characteristics were not different, except for the proportion of gender. Complications occurred in 11 cases (16.4%). Wound infection was the most common complication followed by Mallory-Weiss tear, tube leakage, fever and pneumonia. Twenty six patients (38.8%) died during the follow-up period, and the 30 day mortality rate was 2.7%. Average survival of dementia and non-dementia patients was 12 months and 25 months, respectively. Dementia patients showed a tendency for shorter survival, although it was insignificant (p=0.068). Dementia was the only predictor of mortality that showed significance (p=0.006). CONCLUSION: In this study there was a tendency for shorter survival in dementia patients and dementia was the only significant predictor of mortality.

Transesophageal echocardiography (TEE)-induced Mallory-Weiss laceration in a patient who underwent aortic and mitral valve replacement: A case report / 대한마취과학회지

Transesophageal echocardiography (TEE) is a relatively noninvasive and highly valuable diagnostic modality to monitor cardiac surgery. TEE is utilized to estimate the results of the surgical correction or the cardiac function on a real time basis. Accordingly, the frequency of TEE usage is increasing. Previous studies have shown low risk of TEE-associated complications; nonetheless, major gastrointestinal trauma can occur on a rare occasion. We herein present a case of Mallory-Weiss laceration after an intraoperative TEE examination.

Extensive Gastric Mucosal Laceration During Endoscopic Examination / 대한소화기내시경학회지

Gastric mucosal lacerations occurring during the course of upper gastroduodenal endoscopy are apparently rare. The location and extent of the lesion are little different from the usual one found in the Mallory-Weiss tear. But the pathogenesis of the gastric mucosal tear is similar to that of Mallory-Weiss tear. Hiatal hernia, atrophic gastritis, and old age are predisposing factors for Mallory-Weiss tear. There is currently only one report about extensive gastric mucosal laceration during performance of endoscopy in an elderly patient. During a standard diagnostic endoscopic procedure, we experienced extensive gastric mucosal laceration that ranged from the gastroesophageal junction to the gastric angle in an elderly woman Furthermore, her body surface area and stomach size were very small. The patient was treated successfully with hemoclip application for the laceration. We report on the case along with a review of the relevant literature.

A Gigantic Gastric Mucosal Rupture When Performing Endoscopy under Conscious Sedation in a Patient with Hiatal Hernia / 대한소화기내시경학회지

Mallory-Weiss syndrome is a tear in the gastro-esophageal junction or its adjacent mucosa, and this occurs due to nausea or vomiting that is caused by various etiologic factors. It may occur in patients with excessive retching and struggling when undergoing upper gastrointestinal endoscopy, and its underlying factors are esophageal hiatal hernia, atrophic gastritis and old age. There are currently only rare reports about gigantic gastric mucosal rupture during performance of upper gastrointestinal endoscopy in patients with esophageal hiatal hernia. We recently experienced a 76-year-old woman who developed a gigantic gastric mucosal rupture that ranged from the gastro-esophageal junction to the gastric angle. This occurred during performance of standard upper gastrointestinal endoscopy with the patient under sedation and the patient had a concurrent esophageal hiatal hernia. The patient was treated conservatively for the rupture. Herein we report on our case along with a review of the relevant literature.

Clinical Features of Iatrogenic Mallory-Weiss Syndrome / 대한소화기내시경학회지

BACKGROUND/AIMS: The detection of iatrogenic Mallory-Weiss syndrome during the course of upper GI endoscopy is apparently rare. The aim of this study was identify the clinical features of the disease and associated medical conditions. METHODS: We retrospectively analyzed 46 cases (0.08%) of iatrogenic Mallory- Weiss syndrome identified from 54,188 consecutive upper GI endoscopies performed at our institution during a period of 85 months. RESULTS: A total of 36 patients (78.2%) had retching or belching during the procedure. Hiatal hernias were noted in 20 patients (43.5%). We identified a difference of the attack rate by sex and age for iatrogenic Mallory-Weiss syndrome; the disorder developed predominantly in men. All of the patients had a mucosal tear and oozing and 16 patients underwent endoscopic hemostasis. After being diagnosed with iatrogenic Mallory-Weiss syndrome, 17 patients underwent follow- up endoscopy and all of the patients showed good results without rebleeding. No patient showed a complicated clinical course. CONCLUSIONS: A small number of patients had iatrogenic Mallory-Weiss syndrome and most of the patients showed a good prognosis. If there is a predictable risk factor identified during an upper GI endoscopy or an associated medical condition, special care needs to be taken to minimize belching or retching.

Syndrome de Wilkie au decours d'un Syndrome Mallory Weiss

Nous rapportons un syndrome de Wilkie; observe chez une jeune fille de vingt ans; au decours d'une hemorragie digestive declenchee apres des vomissements iteratifs. Cette affection est rare; parfois grave entrainant des complications hydro-electrolytiques et mecaniques. Elle resulte de la compression extrinseque du troisieme duodenum dans l'angle constitue par l'artere mesenterique superieure en avant et l'ensemble aorte-rachis lombaire en arriere. Beaucoup de facteurs predisposant en sont incrimines. Cette affection realise une occlusion intestinale haute. Le diagnostic est etabli a partir d'un transit oesophago-gastro-duodenal. L'intervention chirurgicale n'est envisagee qu'apres echec du traitement medical

Dissecting Intramural Hematoma of the Esophagus: A case report / 대한흉부외과학회지

Dissection intramural hematoma of the esophagus (DIHO) is a rare, but well-documented condition that is part of the spectrum of acute esophageal injuries; these include the more common Mallory-Weiss tear and Boerhaave's syndrome. This disorder is predominantly seen in women during their sixth or seventh decade and the disease has various etiologies, but the pathogenesis has yet to be clarified. The triad of symptoms for this disorder includes retrosternal pain, hematemesis and odynophagia. It is important to differentiate esophageal submucosal dissection form other disorders that have a similar appearance, such as Mallory-Weiss syndrome and esophageal perforation because the prognosis of DIHO is excellent with conservative therapy and these other diseases require surgical treatment. We report here on a case of a dissecting intramural hematoma of the esophagus that was preoperatively misdiagnosed as the submucosal tumor of the esophagus preoperatively, and it was confirmed by Video-assisted thoracic surgery.

Clinical Characteristics of Acute Upper Gastrointestinal Bleeding in a Tertiary Referral Center / 대한소화기학회지

BACKGROUND/AIMS: Acute upper gastrointestinal bleeding (UGIB) is still responsible for significant morbidity in spite of various therapeutic advances. The aims of this study were to evaluate the success rate in managing UGIB and predicting factors that affected clinical courses. METHODS: From August 2003 to April 2005, medical data (registered in a standard database categories) of 318 patients who underwent endoscopic examination to evaluate UGIB were analyzed. Early and final treatment success rates were evaluated on the next day and 14 days after the initial endoscopic procedures respectively (or the day of discharge). RESULTS: Main causes of UGIB were peptic ulcer (50.9%), varices (28.3%), Mallory-Weiss syndrome (10.3%). Endoscopic treatments were tried in 200 patients (63.0%). Number of patients who underwent operation and deaths were 4 (1.3%) and 13 (4.1%), respectively. Early and final success rates were 86.2% and 94.0%. Independent prognostic factors related with early success rates were volume of transfusion (OR 0.80, 95% CI 0.72-0.89, p<0.001) and bleeding during the ventilator care (OR 0.03, 95% CI 0.01-0.31, p<0.001), whereas those factors related with final success rates were volume of transfusion (OR 0.79, 95% CI 0.69-0.90, p<0.001), bleeding during the stay in intensive care unit (ICU) (OR 0.12, 95% CI 0.13-0.49, p<0.001). CONCLUSIONS: Early and final success rates of bleeding control were 86.2% and 94.0% in acute UGIB. Volume of transfusion, bleeding during ICU state or ventilator state were important predictive factors of the treatment failure.

Hemorragia digestiva alta no originada por várices / Nonvariceal upper gastrointestinal bleeding

La hemorragia digestiva alta no originada por várices, continúa siendo un desafío para el médico gastroenterólogo tanto desde el punto de vista diagnóstico como de manejo. La causa más frecuente sigue siendo un desafío para el médico gastroenterólogo tanto desde el punto de vista diagnóstico como de manejo. La causa más frecuente sigue siendo la úlcera péptica, con un 50 por ciento en promedio en la literatura publicada. Las hemorragias activas más severas son provocadas por la lesión de Dieulafoy y algunas formas de presentación de hemorragia por úlcera. Por lo general, son menos severas las hemorragias producidas por el mallory-Weiss, gastritis, esofagitis, las ectasias vasculares o angiodisplasias y el "watermelon stomach" (una variante de esta última). Las angiodisplasias, son más una causa de una hemorragia crónica. Los nuevos avances en el tratamiento de estas lesiones, básicamente con la endoscopía terapéutica en estigmas de alto riesgo de recurrencia, el uso de supresión ácida más profunda y sostenida con los inhibidores de nomba de protones y el manejo en unidades especializadas e interdisciplinario, ha permitido una reducción significativa en la recurrencia de hemorragia, necesidad de transfusiones, necesidad de cirugía y días de hospitalización. Y, en algunos estudios se demuestra también una reducción en la mortalidad, de un 10 por ciento que era el estándar, a 2,3 - 5,4 por ciento, según revisiones últimas.

Causes of severe upper gastrointestinal bleeding on the basis of endoscopic findings

To describe the common causes of severe upper gastrointestinal [GI] bleeding in a tertiary care teaching hospital. This study was carried out in Gastroenterology Department Postgraduate Medical Institute, Hayatabad Medical Complex Peshawar from 1st September 2003 to 31st July 2005. Study was conducted on all patients who presented with severe upper GI bleeding. The patients were first stabilized hemodynamically and were kept empty stomach for at least 6-12 hours before procedure. Upper GI endoscopy was performed and the endoscopic findings were recorded. Out of 350 patients included in the study, 200 [57%] were males and 150 [43%] were females. The age ranged from 14 years to 75 years. Variceal bleed was the most common cause in 45.7% [n=160] cases followed by peptic ulcer in 31.4% [n=110] cases. Gastroesophageal reflex disease was noted in 10% [n=35], carcinoma of the stomach in 5.7% [n=20] of the cases and Mallory-Weiss tears in 4% [n=14] cases. Out of 160 patients with varices, 62.5% [n=100] were having esophageal varices. Out of 110 peptic ulcer cases, 63.6% [n=70] were having duodenal ulcer and 26.4% [n=29] were having NSAID induced peptic erosions. Variceal bleeding secondary to portal hypertension and peptic ulcer diseases are the most common causes of upper G I bleeding in our setup

Clinical Features of Gastrointestinal Bleeding in Patients with Chronic Renal Failure / 대한소화기내시경학회지

BACKGROUND/AIMS: Gastrointestinal bleeding (GIB) in patients with chronic renal failure (CRF) is a common complication with a high mortality. However, the cause or mechanism of this condition is unclear. Therefore, this study investigated the clinical features of GIB in patients with CRF. METHODS: The clinical features of 35 patients with CRF who were admitted to the Uijeongbu St. Mary's Hospital for GIB from January 1998 to August 2003 were examined retrospectively. RESULTS: Thirty-five out of 803 patients had CRF (4.4%). The mean age of those with CRF was 62+/-11 years and 16 patients were male. The treatment for CRF was hemodialysis in 22 (62.9%), pre-dialysis in 10 (28.6%) and peritoneal dialysis in 3 (8.6%). The cause of GIB in CRF patients was an ulcer (45.7%), vascular disease (37.1%), hemorrhagic gastritis (8.6%), and Mallory-Weiss laceration (2.9%), etc. Rebleeding after the first treatment occurred in 5 patients (14.3%). Three of these patients (60%) had vascular disease. Surgical treatment for rebleeding was performed in 3 patients (60%) and the mortality rate in rebleeding patients was 60%. CONCLUSIONS: The most common cause of GIB in CRF patients is an ulcer followed by vascular disease. Vascular disease in cases with rebleeding is high with a high mortality rate.