Risk factors for Mallory-Weiss Tear during endoscopic submucosal dissection of superficial esophageal neoplasms.

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.

Clinical Outcomes of Patients with Non-ulcer and Non-variceal Upper Gastrointestinal Bleeding: A Prospective Multicenter Study of Risk Prediction Using a Scoring System.

BACKGROUND AND AIMS: Compared with ulcer bleeding (UB) in non-variceal upper gastrointestinal bleeding (NVUGIB), non-ulcer bleeding (NUB) is often considered to have a low risk of poor outcomes and is treated less intensively without any risk stratification. We conducted this study to assess the predictability of scoring systems for NUB and compare the outcomes of NUB and UB. METHODS: A total of 1831 UGIB patients were registered in the database during the period from February 2011 to December 2013. Among them, 1424 patients with NVUGIB were divided into two groups: Group UB (1101 patients with peptic ulcer bleeding) and Group NUB (323 patients with non-peptic ulcer-related bleeding). RESULTS: The most common cause of bleeding in Group NUB was Mallory-Weiss tears (51.1%), followed by Dieulafoy lesions (18.9%). A receiver operating characteristic (ROC) analysis revealed that the pre-Rockall score [area under the ROC (AUROC) = 0.798; 95% CI 0.707-0.890] and full Rockall score (AUROC = 0.794; 95% CI 0.693-0.895) were relatively good at predicting overall mortality in NUB. Glasgow-Blatchford score (AUROC = 0.783; 95% CI 0.730-0.836) was the most closely correlated with the need for clinical intervention in NUB. Those who had Glasgow-Blatchford score of 0 did not require any interventions, including blood transfusions. There were no statistical differences in overall mortality (p = 0.387), bleeding-related mortality (p = 0.447), or the incidence of re-bleeding (p = 0.117) between the two groups. CONCLUSIONS: Scoring systems are useful to predict mortality and the need for clinical intervention in patients with NUB.

Malory-Weis syndrome based on own experience - diagnostics and modern principles of management.

UNLABELLED: Every gastrointestinal bleeding is an immediate threat to life, requiring close supervision in a hospital setting and making it mandatory to perform verification and endoscopic intervention. In some cases of a dynamic course, in order to make up deficiencies, it is necessary to use blood and blood products. One of the causes of bleeding located proximally to the ligament of Treitz is damage to the mucous membrane and deeper layers of the gastroesophageal junction, called Mallory-Weiss syndrome. The aim of the study was retrospective analysis of a selected group of patients with symptomatic upper gastrointestinal bleeding in the course of Mallory-Weiss syndrome, identification of typical characteristics of this disease entity in the studied population as well as demonstration of the effectiveness of endoscopic treatment using argon plasma coagulation (APC). 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.

Risk Factors for Aspiration Pneumonia After Endoscopic Hemostasis.

BACKGROUND: Although all types of endoscopic procedures harbor risk of aspiration, little is understood about risk factors for aspiration pneumonia developing after endoscopic hemostasis. AIMS: The present study aimed to identify risk factors for aspiration pneumonia after endoscopic hemostasis. METHODS: Charts from consecutive patients with upper gastrointestinal bleeding that had been treated by endoscopic hemostasis at a single center between January 2004 and January 2015 were retrospectively reviewed. Patient information and clinical characteristics including cause of hemorrhage, established prognostic scales, laboratory data, comorbidities, medications, duration of endoscopic hemostasis, vital signs, sedative use, and the main operator during the procedure were compared between patients who developed aspiration pneumonia and those who did not. RESULTS: Aspiration pneumonia developed in 24 (4.8%) of 504 patients after endoscopic hemostasis. Endotracheal intubation was required for three of them, and one died of the complication. Multivariate analysis revealed that age >75 years (odds ratio (OR) 4.4; 95% confidence interval (CI) 1.5-13.6; p = 0.0073), procedural duration >30 min (OR 5.6; 95% CI 1.9-18.2; p = 0.0023), hemodialysis (OR 3.6; 95% CI 1.2-11; p = 0.024), and a history of stroke (OR 3.8; 95% CI 1-14; p = 0.041) were independent risk factors for developing aspiration pneumonia. CONCLUSIONS: Specific risk factors for aspiration pneumonia after endoscopic hemostasis were identified. Endoscopists should carefully consider aspiration pneumonia when managing older patients who are on hemodialysis, have a history of stroke, and undergo a longer procedure.

Outcomes of Propofol Sedation During Emergency Endoscopy Performed for Upper Gastrointestinal Bleeding.

BACKGROUND: Although propofol-based sedation can be used during emergency endoscopy for upper gastrointestinal bleeding (UGIB), there is a potential risk of sedation-related adverse events, especially in patients with variceal bleeding. AIM: We compared adverse events related to propofol-based sedation during emergency endoscopy between patients with non-variceal and variceal bleeding. METHODS: Clinical records of patients who underwent emergency endoscopy for UGIB under sedation were reviewed. Adverse events, including shock, hypoxia, and paradoxical reaction, were compared between the non-variceal and variceal bleeding groups. RESULTS: Of 703 endoscopies, 539 and 164 were performed for non-variceal and variceal bleeding, respectively. Shock was more common in patients with variceal bleeding compared to those with non-variceal bleeding (12.2 vs. 3.5%, P < 0.001). All patients except one recovered from shock after normal saline hydration, and emergency endoscopy could be finished without interruption in most cases. The incidence of hypoxia and paradoxical reaction did not differ based on the source of bleeding (non-variceal bleeding vs. variceal bleeding: hypoxia, 3.5 vs. 1.8%, P = 0.275; paradoxical reaction interfering with the procedure, 4.1 vs. 5.5%, P = 0.442). CONCLUSIONS: Although shock was more common in patients with variceal bleeding compared to those with non-variceal bleeding, most cases could be controlled without procedure interruption. Paradoxical reaction, rather than shock or hypoxia, was the most common cause of procedure interruption in patients with variceal bleeding, but the rate did not differ between patients with non-variceal and variceal bleeding.

Mallory-Weiss syndrome: clinical and endoscopic characteristics.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

The Blatchford score is an useful index in the management of Mallory-Weiss tear and gastrointestinal bleeding: experience from an urban community hospital.

OBJECTIVES: The purpose of this study was to determine the utility of individual clinical parameters as well as a composite index like the Blatchford score in predicting the need for endoscopic intervention and prognosticating the out come in patients with Mallory Weiss tear presenting with gastrointestinal bleeding. METHODS: We retrospectively reviewed our endoscopy database and our EMR system to identify patients with Mallory Weiss tear and collect relevant data. RESULTS: A total of 38 cases with Mallory-Weiss tear were identified at our center over a 5 year period. Thirty-two patients presented with gastrointestinal bleeding constituting 3.1% of all cases presenting with upper gastrointestinal bleeding. Nine (28%) of 32 patients were found to have active bleeding or stigmata of recent bleeding at endoscopy and required endoscopic therapy. The Blatchford score ranged from 0 to 11 in the patients with gastrointestinal bleeding. Nine patients had a Blatchford score < 6 (four 0, five 1-4) while 23 patients had a score > 6. None of the patients with a score < 6 required endoscopic intervention or a blood transfusion while 9 (39%) patients with a score > 6 required endoscopic intervention and 17 (74%) required a blood transfusion. Length of stay was significantly longer in patients with a score > 6. CONCLUSIONS: The Blatchford score can be a useful index to risk stratify patients with Mallory Weiss tear who present with gastrointestinal bleeding with regards to hospital admission and identifying patients who warrant urgent endoscopic intervention, require blood transfusion and are likely to have a longer length of stay.

Upper gastrointestinal haemorrhage and deprivation: a nationwide cohort study of health inequality in hospital admissions.

OBJECTIVE: 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. DESIGN: Population-based cohort study. SETTING: All English National Health Service hospitals. POPULATION: 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. OUTCOME MEASURES: 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. RESULTS: 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. CONCLUSION: 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.

Characteristics and outcomes of upper gastrointestinal hemorrhage in a tertiary referral hospital.

BACKGROUND AND AIMS: Upper gastrointestinal hemorrhage remains a problem in spite of improved diagnosis and management. There is sparse knowledge of recent epidemiology and outcomes. We wanted to evaluate the characteristics and outcomes of patients with upper gastrointestinal hemorrhage over a 4-year period in a tertiary referral hospital. METHODS: We prospectively collected data on patients admitted with upper gastrointestinal hemorrhage to John Hunter Hospital between August 2004 and December 2008. Variables of interest included age, gender, co-morbidities, and time to endoscopy. Main outcomes included etiology, treatment, and survival. Variceal and non-variceal bleeds were analyzed separately. RESULTS: There were 792 admissions from 734 unique patients (61% male) with a mean age of 66 years. The most frequent causes of non-variceal bleeds (88%) included ulcers 265 (33%); Mallory Weiss tear 91 (11%); esophagitis 60 (8%), and malignancy 29 (4%). Most patients had one or more co-morbidity (74%). Transfusion was not employed in 41%. Overall mortality was 4.0% (5.4% in the variceal and 3.9% in the non-variceal group). Only 1.9% of patients had surgery. CONCLUSIONS: Patients presenting with upper gastrointestinal hemorrhage are overall elderly with significant co-morbidities. Our overall mortality and surgery rates are lower than in previously published international data.

Review on hyperemesis gravidarum.

Hyperemesis gravidarum is severe, intractable nausea and vomiting affecting 0.3-2% of pregnancies. It has a complex multifactorial aetiology. This review explores the current literature relating to the clinical manifestations, differential diagnosis, epidemiology, possible aetiology, maternal and fetal complications, and evidence-based management of hyperemesis.

[Epidemiology of gastrointestinal bleeding in the elderly]. / Epidemiologie gastrointestinaler Blutungen bei älteren Patienten.

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

Herpes simplex esophagitis in the immunocompetent host.

We report here a case of herpes esophagitis with Mallory-Weiss syndrome in an immunocompetent host. A 26-year-old man was admitted to our hospital because of common cold symptoms and eruptions on the body. On day 2 after hospitalization, the patient showed high-grade fever, odynophagia and hematemesis. Upper gastrointestinal endoscopic examination showed multiple ulcerations throughout the mid- and distal esophagus. Bleeding from a Mallory-Weiss tear was also seen. Follow-up endoscopic examinations showed whitish exudates on day 5. Histological examination of biopsy specimens showed Cowdry type A intranuclear inclusion bodies in epithelial cells. Positive staining of a specific antibody against herpes simplex virus-1 (HSV-1) was seen in the nuclei of esophageal epithelial cells. Primary HSV-1 infection was suspected because ELISA titers of serum IgM antibody against HSV-1 were high and titers of serum IgG antibody against HSV-1 increased from an almost cut-off ratio. A diagnosis of herpes esophagitis in an immunocompetent host was made. Our case is the first report of herpes esophagitis with Mallory-Weiss syndrome in the immunocompetent host. It is important to remind herpes esophagitis in cases of severe odynophagia even in immunocompetent hosts.

Mallory-Weiss tear: predisposing factors and predictors of a complicated course.

OBJECTIVES: Little has been published regarding predictors of a complicated course after Mallory-Weiss tear (MWT). The aims of this study were to identify risk factors for a Mallory-Weiss tear and factors predictive of a complicated course. METHODS: At our university hospital, we searched a computerized endoscopy database. At our Veterans Affairs hospital we manually searched printed endoscopy reports. Proposed risk factors for MWT were: history of alcohol use, recent alcohol binge, nonbloody initial emesis, anticoagulation, other coagulopathy, nonsteroidal anti-inflammatory use, and hiatal hernia. Proposed predictors of a complicated course were: age, hematemesis, melena, hematochezia, visible vessel, adherent clot, active bleeding, multiple tears, other pathology at endoscopy, admission Hct, hypotension or orthostatic changes, and coagulopathy. A complicated course was defined on the basis of >6 U of blood transfused, rebleeding, angiography, surgery, or death. Predictors of a complicated course were evaluated using the Mann-Whitney U test or Fisher exact test. RESULTS: A total of 73 cases were reviewed. The most common risk factor was alcohol use, which was found in 44% of cases. In all, 23% of patients had no risk factors. Of the patients, 17 (23%) had a complicated course. Patients with a complicated course had a lower admission Hct (p = 0.009) and active bleeding at initial endoscopy (p = 0.013). CONCLUSION: The predictive value of active bleeding supports early endoscopy for stratification and intervention.

Mallory-Weiss syndrome in children.

The aim of the study was to evaluate the incidence and the etiology of Mallory-Weiss syndrome in children. The study population comprised 2720 children aged 5 months to 18 years who had undergone upper gastrointestinal endoscopy. Mallory-Weiss syndrome was diagnosed in eight (0.3%) of the examined children. Endoscopic examination in five of them revealed linear mucosal tears, mostly above and in one case also below the gastroesophageal junction. In three children a linear scar in the lower portion of the esophagus was seen. No signs of active bleeding were revealed in any of the cases. In four children, Mallory-Weiss syndrome was accompanied by gastritis and duodenitis; two of these children had Helicobacter pylori infection. The concomitant diseases were H. pylori-positive duodenal ulcer (1), bronchial asthma and gastroesophageal reflux disease (1), carbon monoxide poisoning (1). In one case Mallory-Weiss syndrome was diagnosed in early pregnancy. Mallory-Weiss syndrome should be considered, along with others, as a cause of acute upper gastrointestinal bleeding in children. There is a great variety of etiologic factors in Mallory-Weiss syndrome in children.

Retrospective analysis of iatrogenic Mallory-Weiss tears occurring during upper gastrointestinal endoscopy.

BACKGROUND/AIMS: This study was made to determine the incidence and natural history of iatrogenic Mallory-Weiss tears. PATIENTS AND METHODS: We retrospectively analyzed twelve cases of iatrogenic Mallory-Weiss tears identified from 2,461 consecutive upper gastrointestinal endoscopies performed at our institution over a period of twenty-two months. RESULTS: In all cases, bleeding stopped spontaneously without the need of blood transfusions, endoscopic hemostasis therapy or any other interventions. Eight patients (67%) had retching or struggling during the procedure. Hiatus hernias were noted in three patients (25%). CONCLUSIONS: Iatrogenic Mallory-Weiss tears are rare and generally have a benign course. They tend to occur mostly in patients who have experienced excessive retching or struggling during endoscopy.

Mallory-Weiss tears occurring during endoscopy: a report of seven cases.

Mallory-Weiss tears occurring during the course of upper gastrointestinal endoscopy are apparently rare. The present report describes seven cases of iatrogenic gastro-oesophageal tears encountered during 10,000 endoscopic examinations over a period of six years. Five of the seven patients were female and six patients were aged 75 years or older. Six patients had hiatal hernias. The site of the mucosal tear was similar in all patients, extending from a V-shaped breach at the gastro-oesophageal junction inferiorly along the lesser curve for a variable distance of up to 8 cm. Neither retching nor struggling during the procedure contributed to the development of the lesion in any of the patients. One patient suffered from a haematemesis which required transfusion, and in a further patient the tear resulted in a haematemesis and gastric perforation necessitating laparotomy. The study indicates that Mallory-Weiss tears complicating endoscopy occur especially in elderly, female patients with hiatal hernias. The importance of admitting patients with this complication to hospital for overnight observation is recommended in view of the possible development of haemorrhage or perforation.

Mallory-Weiss syndrome in children.

We have described a case of Mallory-Weiss syndrome in a 15-year-old girl, and reviewed five other cases in children. Endoscopy was used to make the diagnosis in each case. All patients were successfully managed using conservative, nonoperative therapy, and no recurrent bleeding has been reported. Mallory-Weiss syndrome should be considered in the differential diagnosis of upper gastrointestinal bleeding in the pediatric patient.