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Endoscopic hemoclipping for upper GI bleeding due to Mallory-Weiss syndrome
Endoscopic hemoclipping for upper GI bleeding due to Mallory-Weiss syndrome Yasuharu Yamaguchi, MD, Taro Yamato, MD, Naoya Katsumi, MD, Katsuro Morozumi, MD, Takashi Abe, MD, Hitoshi Ishida, MD, Shin’ichi Takahashi, MD Tokyo, Japan
Background: Endoscopic hemoclipping is known to be highly effective as hemostatic treatment for upper gastrointestinal bleeding. However, the efficacy and safety of hemoclipping for MalloryWeiss syndrome (MWS) have not been reported. Thus, the aim of the present study was to assess prospectively the usefulness of endoscopic hemoclipping for MWS bleeding. Methods: This study was conducted from January 1994 to August 1999. Hemoclipping was performed when active bleeding (spurting, streaming or oozing), visible vessels or fresh adhesive clots were found on endoscopic examination. Patients who did not have any of these findings were conservatively treated. Follow-up endoscopy was performed within 24 hours, after 5 days and between 1 and 2 months after the procedure. Results: MWS was diagnosed in a total of 58 patients during the study. Hemoclipping was performed in 26 patients and was technically successful in all cases. The average number of hemoclips used was 2.8 ± 1.6 (range 1 to 8). The number of hemoclips required for hemostasis depended on the nature of the bleeding. No complications, recurrent bleeding, or deaths resulted. Follow-up endoscopy showed no evidence of hemoclip-induced tissue injury and no impairment of Mallory-Weiss tears. Conclusion: Endoscopic hemoclipping provided an effective and safe modality for obtaining hemostasis when bleeding is due to MWS. (Gastrointest Endosc 2001;53:427-30.)
Mallory and Weiss1 in 1929 described upper GI (UGI) bleeding arising in the gastric cardia following persistent retching and vomiting after episodes of excessive alcohol intake. Mallory-Weiss syndrome (MWS) was rarely diagnosed before the advent of endoscopy. As a result of the increased use of endoscopy, MWS is now considered to be the cause of UGI bleeding in 4.5% to 11% of cases.2-7 In most cases MWS bleeding stops spontaneously. However, between 14% and 30% of patients require surgery or other therapeutic approaches such as balloon tamponade, arterial embolization, or systemic or selective arterial infusion of vasopressin.5,7-9 Endoscopy is the treatment of choice for acute UGI bleeding.10-16 Hemoclipping has been shown to be highly effective for treating nonvariceal GI bleeding.17-19 However, the efficacy and safety of hemoclipping for bleeding due to MWS have not been reported. Thus the aim of the present study was to assess prospectively the Received April 24, 2000. For revision July 11, 2000. Accepted September 22, 2000. From the Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan. Reprint requests: Yasuharu Yamaguchi, MD, The Third Department of Internal Medicine, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan. Copyright © 2001 by the American Society for Gastrointestinal Endoscopy 0016-5107/2001/$35.00 + 0 37/1/111774 doi:10.1067/mge.2001.111774 VOLUME 53, NO. 4, 2001
usefulness of endoscopic hemoclipping as a method for control of bleeding due to MWS. MATERIALS AND METHODS This study was conducted during a 5-year period beginning in January 1994. All patients with UGI bleeding manifested by hematemesis or melena who underwent emergency endoscopy were included in this study. Informed consent was obtained from all patients before enrollment, and this research was carried out in accordance with the Helsinki Declaration as revised in 1989. After basic life support all patients underwent emergency endoscopy within 12 hours of the onset of UGI bleeding. Cardiogram, blood pressure, and oxygen saturation were monitored. A Mallory-Weiss tear was considered responsible for the UGI bleeding episode when active bleeding, visible vessels, or recent hemorrhagic stigmata were present or in the absence of another possible source of bleeding in the UGI tract during the endoscopic examination. Hemoclipping was performed when active bleeding (arterial spurting, micropulsatile streaming, or oozing), visible vessels, or fresh adherent clots were found. Patients with old adherent clot and clean based linear tears in the esophagogastric junction mucosa as the only possible origin of bleeding were conservatively treated. From January 1992 to December 1993, before the present study began, a total of 17 patients with MWS bleeding underwent emergency endoscopy. During that period, Mallory-Weiss tears were treated endoscopically only when active bleeding or a visible vessel was present. However, during emergency endoscopy, active bleeding GASTROINTESTINAL ENDOSCOPY
427
Y Yamaguchi, T Yamato, N Katsumi, et al.
A
Endoscopic hemoclipping for bleeding Mallory-Weiss tears
dure to check for recurrent bleeding, new Mallory-Weiss tears or accidental hemoclip-induced tissue injury. All endoscopic procedures were performed by members of the research team, which consisted of 9 staff gastroenterologists with a special interest in therapeutic endoscopy. At least 2 members of the research team were on duty at all times. If the determination as to whether a visible vessel, fresh adherent clot or old adherent clot was difficult, the opinions of 2 or more members of the research team were sought during emergency endoscopy. The presence of shock was defined as a pulse rate greater than 100 beats per minute, a systolic blood pressure less than 100 mm Hg, or both. Recurrent bleeding was defined as fresh hematemesis or melena, a sudden fall in systolic blood pressure (more than 30 mm Hg), or a fall in hemoglobin level of 2 gm/dL or more after treatment. Student t test was used for statistical analysis, and a p value of less than 0.05 was considered significant.
RESULTS
B Figure 1. A, Endoscopic view shows active bleeding from Mallory-Weiss tear (black arrows indicate Mallory-Weiss tear; white arrow indicates active bleeding). B, Endoscopic appearance after active bleeding has been stopped and the Mallory-Weiss tear closed with hemoclips. occurred in 1 patient with MWS with a fresh adherent clot. Therefore, in the present study, the therapeutic protocol for MWS bleeding was changed to include MalloryWeiss tears with fresh adherent clots. Endoscopic procedures were performed with videoendoscopes (GIF-Q200, XQ200; Olympus Optical Co., Ltd., Tokyo, Japan). Hemoclipping was carried out according to the procedures developed by Hachisu.17 The stainless steel hemoclips (MD850; Olympus) had prongs 6 mm long and 1.2 mm wide. The distance between the prongs, when fully opened, was 10 mm. The hemoclips were placed with an application device (HX-2L, HX-3L or HX-5 LR-1; Olympus). In terms of technique, hemoclips were applied directly to close Mallory-Weiss tears if active bleeding, visible vessels or fresh adherent clots were present (Fig. 1). After endoscopic treatment, all patients were treated with H2 receptor antagonists and antiemetic drugs in the standard doses. Follow-up endoscopy was performed within 24 hours, after 5 days and between 1 and 2 months after the proce428
GASTROINTESTINAL ENDOSCOPY
Emergency endoscopy was performed on 1082 patients from January 1994 to August 1999. Among these patients, bleeding due to MWS was diagnosed in a total of 58 patients. Arterial spurting was found in 4 patients (7%), micropulsatile streaming in 6 (10%), oozing in 7 (12%), a visible vessel in 1 (2%), fresh adherent clot in 8 (14%), old adherent clot in 12 (21%) and clean based linear tears in 20 patients (34%). In most cases, the diagnosis was not difficult and required no discussion among the research team. Of these 58 patients, 26 patients (men/women, 23/3; age 49.7 ± 16.1 years [mean ± SD]) were treated by hemoclipping according to the study protocol. The average number of hemoclips used was 2.8 ± 1.6 (range 1 to 8). Four patients received a single clip. For the remaining 22 patients, it was necessary to use at least 2 hemoclips to close the tears proximally and distally to achieve hemostasis. On average, more hemoclips were required in patients with arterial spurting bleeding to achieve hemostasis than in those with oozing (5.2 ± 1.9 vs. 2.4 ± 1.3, p = 0.016). Patients with active bleeding (spurting, streaming or oozing) generally required more hemoclips than patients without active bleeding (visible vessels and fresh adherent clots) (3.2 ± 1.7 vs. 1.9 ± 0.9, p = 0.043). Of the 26 patients who were treated by hemoclipping, 14 (54%) had concomitant disease: liver cirrhosis in 9 patients, chronic renal failure in 2 patients, cerebral vascular disease in 2 patients, and chronic obstructive pulmonary disease in 1 patient. Four patients (15%) were in shock and required more than 800 mL of blood transfusion. Two of the patients with shock had disseminated intravascular coagulation, which was diagnosed according to the criteria proposed by Colman et al.20 However, disseminated intravascular coagulation was successfully controlled. VOLUME 53, NO. 4, 2001
Endoscopic hemoclipping for bleeding Mallory-Weiss tears
During emergency endoscopy, placement of hemoclips was technically successful in all patients. Hemostasis was achieved in all patients and there was no recurrence of bleeding. Endoscopy 5 days after the original procedure showed no evidence of hemoclipinduced tissue injury and no difference in the healing process between hemoclipping and nonhemoclipping patients. Hemoclips were well retained. Endoscopy between 1 and 2 months (42 ± 9.3 days [mean ± SD]) after the original procedure showed that all hemoclips in 17 patients had dislodged spontaneously leaving a clean linear scar at the esophagogastric junction. The hemoclips were passed in the feces without complications. In the other 9 patients the hemoclips were still present at the esophagogastric junction. However, the tears had healed cleanly and reepithelialization was observed. These patients did not report any discomfort. No complications related to the endoscopic procedures and no deaths occurred during the period of this study. DISCUSSION MWS bleeding is usually mild and self-limited. Therefore, the conservative management of MWSrelated hemorrhage consists of stabilization of vital signs with volume replacement, administration of H2 receptor antagonists and antiemetic drugs, and general supportive care. However, severe bleeding related to MWS that requires nonsurgical or surgical treatments is well recognized.7-9 Endoscopic treatment of UGI bleeding with sclerotherapy or thermal methods has been widely used for different lesions causing UGI bleeding. However, the potential drawback of thermal methods or the injection of sclerosing agents is that these may cause excessive tissue injury leading to necrosis and perforation.12,15,16,21,22 In particular, these techniques are associated with increased risk because the esophageal wall is thinner than the gastric wall. Bataller et al.15 reported that sclerotherapy was useful for the treatment of MWS bleeding. However, esophageal perforation occurred in 8% of the cases reported in this study. The present study was not a randomized trial. Its purpose was to determine the potential efficacy of hemoclipping for MWS bleeding. Hemoclipping for hemostasis was technically simple in every case. Theoretically, mechanical application of metal hemoclips to Mallory-Weiss tears is an appealing alternative to the currently available hemostatic techniques. Hemoclipping causes less damage to the surrounding tissues than pure ethanol or polidocanol injection or thermal methods such as multipolar electrocoagulation (MPEC). Thus, hemoclipping is believed to be advantageous in cases of MWS bleedVOLUME 53, NO. 4, 2001
Y Yamaguchi, T Yamato, N Katsumi, et al.
ing because it has a smaller risk of esophageal perforation. In the present study hemoclipping was performed in 26 patients (45%). Hemostasis was obtained in all 26 cases without complications. The number of hemoclips required for hemostasis depended on the rate of bleeding. However, even in patients with arterial spurting, hemoclipping was successful. In addition, although 54% of patients in whom hemoclipping was performed had concomitant diseases, all were treated successfully and safely. These results suggest that endoscopic hemoclipping is effective for controlling bleeding due to MWS. A prospective controlled trial of MPEC in the treatment of active UGI bleeding was reported by Laine.23 This study demonstrated that MPEC improves the hospital course of patients with major UGI bleeding due to Mallory-Weiss tear. However, hospital deaths were reported in 13% of the control cases with Mallory-Weiss tears. Because the patients in the present study were not randomized to receive endoscopic versus sham therapy, a definitive conclusion as to the benefit of hemoclipping is not possible. It is necessary to establish criteria for endoscopic hemoclipping in MWS patients with active bleeding (spurting, streaming or oozing) or without active bleeding (visible vessels or fresh adherent clots). However, controlled trials have risk for MWS patients with bleeding, as is clear from Laine’s data on hospital deaths. The present study shows that hemoclipping is safe, easy and effective, even in cases with active bleeding or stigmata of recent bleeding. Hemoclips did not impair the healing of MWS tears, even when the hemoclips were retained for prolonged periods. It appears that endoscopic hemoclipping for any stigmata of MWS bleeding is worthwhile and not harmful. REFERENCES 1. Mallory GK, Weiss S. Hemorrhages from laceration of cardia orifice of the stomach due to vomiting. Am J Med Sci 1929;178:506-10. 2. Sugawa C, Steffes CP, Nakamura R, Sferra JJ, Sferra CS, Sugimura Y, et al. Upper GI bleeding in an urban hospital: etiology, recurrence, and prognosis. Ann Surg 1990;212:521-7. 3. Bratus VD, Fomin PD, Utratin GA, Fedorov EA, Osingol’ts SL. Emergency diagnosis and surgical treatment of acute gastric hemorrhage in the Mallory-Weiss syndrome. Vestn Khir 1986;137:26-30. 4. Jensen DM, Kovacs TOG, Machicado GA, Randall GM, Sue M. Prospective study of the stigmata of hemorrhage and endoscopic and medical treatment of bleeding Mallory-Weiss tears [abstract]. Gastrointest Endosc 1992;38:AB39. 5. Caroli A, Follador R, Gobbi V, Breda P, Ricci G. Mallory-Weiss syndrome: personal experience and review of the literature. Minerva Gastroenterol Dietol 1989;35:7-12. 6. Bubrick MP, Lundeen JW, Onstad GR, Hitchcock CR. Mallory-Weiss syndrome: analysis of fifty-nine cases. Surgery 1980;88:400-5. GASTROINTESTINAL ENDOSCOPY
429
Y Yamaguchi, T Yamato, N Katsumi, et al.
7. Sugawa C, Benishek D, Walt AJ. Mallory-Weiss syndrome. Am J Surg 1983;145:30-3. 8. Hasting PR, Peters KW, Cohn I Jr. Mallory-Weiss syndrome. Am J Surg 1981;142:560-6. 9. Welch GH, McArdle CS, Anderson JR. Balloon tamponade for the control of Mallory-Weiss syndrome in patients with coagulation defects. Br J Surg 1987;74:610-1. 10. Di Felice G. The current role of endoscopy in Mallory-Weiss syndrome. Surg Endosc 1991;11:879-83. 11. Sugawa C, Fujita Y, Ikeda T, Walt AJ. Endoscopic hemostasis of bleeding of the upper gastrointestinal tract by local injection of ninety-eight percent dehydrated ethanol. Surg Gynecol Obstet 1986;162:159-63. 12. Laine L. Multipolar electrocoagulation versus injection therapy in the treatment of bleeding peptic ulcers: a prospective, randomized trial. Gastroenterology 1990;99:1303-6. 13. Konigsrainer A, Sandbichler P, Aigner F, Pernthaler H, Pointner R. Endoscopic sclerotherapy of bleeding MalloryWeiss mucosal tear. Wien Klin Wochenschr 1989;101:734-5. 14. Cook DJ, Guyatt GH, Salena BJ, Laine LA. Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology 1992;102:139-48. 15. Bataller R, Llach J, Salmeron JM, Elizalde JI, Mas A, Pique JM, et al. Endoscopic sclerotherapy in upper gastrointestinal bleeding due to the Mallory-Weiss syndrome. Am J Gastroenterol 1994;89:2147-50.
Endoscopic hemoclipping for bleeding Mallory-Weiss tears
16. Jensen DM, Kovacs T, Randall G, Smith J, Freeman M, Jutabha R, et al. Prospective study of thermal coagulation (Gold probe) versus combination injection and thermal treatment of high risk patients with severe ulcer or Mallory-Weiss bleeding [abstract]. Gastrointest Endosc 1994;40:AB42. 17. Hachisu T. Evaluation of endoscopic hemostasis using an improved clipping apparatus. Surg Endosc 1988;2:13-7. 18. Ohta S, Yukioka T, Ohta S, Miyagatani Y, Matsuda H, Shimazaki S. Hemostatic with endoscopic hemoclipping for severe gastrointestinal bleeding in critically ill patients. Am J Gastroenterol 1996;91:701-4. 19. Chung K, Ham JK, Kim HS, Park SH, Lee MH, Kim SJ, et al. Comparison of the hemostatic efficacy of the endoscopic hemoclip method with hypertonic saline–epinephrine injection and a combination of the two for the management of bleeding peptic ulcers. Gastrointest Endosc 1999;49:13-8. 20. Colman RW, Robby SJ, Minna JD. Disseminated intravascular coagulation (DIC): an approach. Am J Med 1972;52:67989. 21. Muhldorfer SM, Ketos G, Hahn EG, Ell C. Complication of therapeutic gastrointestinal endoscopy. Endoscopy 1992;24:276-83. 22. Chung SC, Leung JW, Sung JY, Lo KK, Li AK. Injection or heat probe for bleeding ulcer. Gastroenterology 1991;100:33-7. 23. Laine L. Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage: a prospective controlled trial. N Engl J Med 1987;316:1613-7.
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430
GASTROINTESTINAL ENDOSCOPY
VOLUME 53, NO. 4, 2001
Background: Endoscopic hemoclipping is known to be highly effective as hemostatic treatment for upper gastrointestinal bleeding. However, the efficacy and safety of hemoclipping for MalloryWeiss syndrome (MWS) have not been reported. Thus, the aim of the present study was to assess prospectively the usefulness of endoscopic hemoclipping for MWS bleeding. Methods: This study was conducted from January 1994 to August 1999. Hemoclipping was performed when active bleeding (spurting, streaming or oozing), visible vessels or fresh adhesive clots were found on endoscopic examination. Patients who did not have any of these findings were conservatively treated. Follow-up endoscopy was performed within 24 hours, after 5 days and between 1 and 2 months after the procedure. Results: MWS was diagnosed in a total of 58 patients during the study. Hemoclipping was performed in 26 patients and was technically successful in all cases. The average number of hemoclips used was 2.8 ± 1.6 (range 1 to 8). The number of hemoclips required for hemostasis depended on the nature of the bleeding. No complications, recurrent bleeding, or deaths resulted. Follow-up endoscopy showed no evidence of hemoclip-induced tissue injury and no impairment of Mallory-Weiss tears. Conclusion: Endoscopic hemoclipping provided an effective and safe modality for obtaining hemostasis when bleeding is due to MWS. (Gastrointest Endosc 2001;53:427-30.)
Mallory and Weiss1 in 1929 described upper GI (UGI) bleeding arising in the gastric cardia following persistent retching and vomiting after episodes of excessive alcohol intake. Mallory-Weiss syndrome (MWS) was rarely diagnosed before the advent of endoscopy. As a result of the increased use of endoscopy, MWS is now considered to be the cause of UGI bleeding in 4.5% to 11% of cases.2-7 In most cases MWS bleeding stops spontaneously. However, between 14% and 30% of patients require surgery or other therapeutic approaches such as balloon tamponade, arterial embolization, or systemic or selective arterial infusion of vasopressin.5,7-9 Endoscopy is the treatment of choice for acute UGI bleeding.10-16 Hemoclipping has been shown to be highly effective for treating nonvariceal GI bleeding.17-19 However, the efficacy and safety of hemoclipping for bleeding due to MWS have not been reported. Thus the aim of the present study was to assess prospectively the Received April 24, 2000. For revision July 11, 2000. Accepted September 22, 2000. From the Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan. Reprint requests: Yasuharu Yamaguchi, MD, The Third Department of Internal Medicine, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan. Copyright © 2001 by the American Society for Gastrointestinal Endoscopy 0016-5107/2001/$35.00 + 0 37/1/111774 doi:10.1067/mge.2001.111774 VOLUME 53, NO. 4, 2001
usefulness of endoscopic hemoclipping as a method for control of bleeding due to MWS. MATERIALS AND METHODS This study was conducted during a 5-year period beginning in January 1994. All patients with UGI bleeding manifested by hematemesis or melena who underwent emergency endoscopy were included in this study. Informed consent was obtained from all patients before enrollment, and this research was carried out in accordance with the Helsinki Declaration as revised in 1989. After basic life support all patients underwent emergency endoscopy within 12 hours of the onset of UGI bleeding. Cardiogram, blood pressure, and oxygen saturation were monitored. A Mallory-Weiss tear was considered responsible for the UGI bleeding episode when active bleeding, visible vessels, or recent hemorrhagic stigmata were present or in the absence of another possible source of bleeding in the UGI tract during the endoscopic examination. Hemoclipping was performed when active bleeding (arterial spurting, micropulsatile streaming, or oozing), visible vessels, or fresh adherent clots were found. Patients with old adherent clot and clean based linear tears in the esophagogastric junction mucosa as the only possible origin of bleeding were conservatively treated. From January 1992 to December 1993, before the present study began, a total of 17 patients with MWS bleeding underwent emergency endoscopy. During that period, Mallory-Weiss tears were treated endoscopically only when active bleeding or a visible vessel was present. However, during emergency endoscopy, active bleeding GASTROINTESTINAL ENDOSCOPY
427
Y Yamaguchi, T Yamato, N Katsumi, et al.
A
Endoscopic hemoclipping for bleeding Mallory-Weiss tears
dure to check for recurrent bleeding, new Mallory-Weiss tears or accidental hemoclip-induced tissue injury. All endoscopic procedures were performed by members of the research team, which consisted of 9 staff gastroenterologists with a special interest in therapeutic endoscopy. At least 2 members of the research team were on duty at all times. If the determination as to whether a visible vessel, fresh adherent clot or old adherent clot was difficult, the opinions of 2 or more members of the research team were sought during emergency endoscopy. The presence of shock was defined as a pulse rate greater than 100 beats per minute, a systolic blood pressure less than 100 mm Hg, or both. Recurrent bleeding was defined as fresh hematemesis or melena, a sudden fall in systolic blood pressure (more than 30 mm Hg), or a fall in hemoglobin level of 2 gm/dL or more after treatment. Student t test was used for statistical analysis, and a p value of less than 0.05 was considered significant.
RESULTS
B Figure 1. A, Endoscopic view shows active bleeding from Mallory-Weiss tear (black arrows indicate Mallory-Weiss tear; white arrow indicates active bleeding). B, Endoscopic appearance after active bleeding has been stopped and the Mallory-Weiss tear closed with hemoclips. occurred in 1 patient with MWS with a fresh adherent clot. Therefore, in the present study, the therapeutic protocol for MWS bleeding was changed to include MalloryWeiss tears with fresh adherent clots. Endoscopic procedures were performed with videoendoscopes (GIF-Q200, XQ200; Olympus Optical Co., Ltd., Tokyo, Japan). Hemoclipping was carried out according to the procedures developed by Hachisu.17 The stainless steel hemoclips (MD850; Olympus) had prongs 6 mm long and 1.2 mm wide. The distance between the prongs, when fully opened, was 10 mm. The hemoclips were placed with an application device (HX-2L, HX-3L or HX-5 LR-1; Olympus). In terms of technique, hemoclips were applied directly to close Mallory-Weiss tears if active bleeding, visible vessels or fresh adherent clots were present (Fig. 1). After endoscopic treatment, all patients were treated with H2 receptor antagonists and antiemetic drugs in the standard doses. Follow-up endoscopy was performed within 24 hours, after 5 days and between 1 and 2 months after the proce428
GASTROINTESTINAL ENDOSCOPY
Emergency endoscopy was performed on 1082 patients from January 1994 to August 1999. Among these patients, bleeding due to MWS was diagnosed in a total of 58 patients. Arterial spurting was found in 4 patients (7%), micropulsatile streaming in 6 (10%), oozing in 7 (12%), a visible vessel in 1 (2%), fresh adherent clot in 8 (14%), old adherent clot in 12 (21%) and clean based linear tears in 20 patients (34%). In most cases, the diagnosis was not difficult and required no discussion among the research team. Of these 58 patients, 26 patients (men/women, 23/3; age 49.7 ± 16.1 years [mean ± SD]) were treated by hemoclipping according to the study protocol. The average number of hemoclips used was 2.8 ± 1.6 (range 1 to 8). Four patients received a single clip. For the remaining 22 patients, it was necessary to use at least 2 hemoclips to close the tears proximally and distally to achieve hemostasis. On average, more hemoclips were required in patients with arterial spurting bleeding to achieve hemostasis than in those with oozing (5.2 ± 1.9 vs. 2.4 ± 1.3, p = 0.016). Patients with active bleeding (spurting, streaming or oozing) generally required more hemoclips than patients without active bleeding (visible vessels and fresh adherent clots) (3.2 ± 1.7 vs. 1.9 ± 0.9, p = 0.043). Of the 26 patients who were treated by hemoclipping, 14 (54%) had concomitant disease: liver cirrhosis in 9 patients, chronic renal failure in 2 patients, cerebral vascular disease in 2 patients, and chronic obstructive pulmonary disease in 1 patient. Four patients (15%) were in shock and required more than 800 mL of blood transfusion. Two of the patients with shock had disseminated intravascular coagulation, which was diagnosed according to the criteria proposed by Colman et al.20 However, disseminated intravascular coagulation was successfully controlled. VOLUME 53, NO. 4, 2001
Endoscopic hemoclipping for bleeding Mallory-Weiss tears
During emergency endoscopy, placement of hemoclips was technically successful in all patients. Hemostasis was achieved in all patients and there was no recurrence of bleeding. Endoscopy 5 days after the original procedure showed no evidence of hemoclipinduced tissue injury and no difference in the healing process between hemoclipping and nonhemoclipping patients. Hemoclips were well retained. Endoscopy between 1 and 2 months (42 ± 9.3 days [mean ± SD]) after the original procedure showed that all hemoclips in 17 patients had dislodged spontaneously leaving a clean linear scar at the esophagogastric junction. The hemoclips were passed in the feces without complications. In the other 9 patients the hemoclips were still present at the esophagogastric junction. However, the tears had healed cleanly and reepithelialization was observed. These patients did not report any discomfort. No complications related to the endoscopic procedures and no deaths occurred during the period of this study. DISCUSSION MWS bleeding is usually mild and self-limited. Therefore, the conservative management of MWSrelated hemorrhage consists of stabilization of vital signs with volume replacement, administration of H2 receptor antagonists and antiemetic drugs, and general supportive care. However, severe bleeding related to MWS that requires nonsurgical or surgical treatments is well recognized.7-9 Endoscopic treatment of UGI bleeding with sclerotherapy or thermal methods has been widely used for different lesions causing UGI bleeding. However, the potential drawback of thermal methods or the injection of sclerosing agents is that these may cause excessive tissue injury leading to necrosis and perforation.12,15,16,21,22 In particular, these techniques are associated with increased risk because the esophageal wall is thinner than the gastric wall. Bataller et al.15 reported that sclerotherapy was useful for the treatment of MWS bleeding. However, esophageal perforation occurred in 8% of the cases reported in this study. The present study was not a randomized trial. Its purpose was to determine the potential efficacy of hemoclipping for MWS bleeding. Hemoclipping for hemostasis was technically simple in every case. Theoretically, mechanical application of metal hemoclips to Mallory-Weiss tears is an appealing alternative to the currently available hemostatic techniques. Hemoclipping causes less damage to the surrounding tissues than pure ethanol or polidocanol injection or thermal methods such as multipolar electrocoagulation (MPEC). Thus, hemoclipping is believed to be advantageous in cases of MWS bleedVOLUME 53, NO. 4, 2001
Y Yamaguchi, T Yamato, N Katsumi, et al.
ing because it has a smaller risk of esophageal perforation. In the present study hemoclipping was performed in 26 patients (45%). Hemostasis was obtained in all 26 cases without complications. The number of hemoclips required for hemostasis depended on the rate of bleeding. However, even in patients with arterial spurting, hemoclipping was successful. In addition, although 54% of patients in whom hemoclipping was performed had concomitant diseases, all were treated successfully and safely. These results suggest that endoscopic hemoclipping is effective for controlling bleeding due to MWS. A prospective controlled trial of MPEC in the treatment of active UGI bleeding was reported by Laine.23 This study demonstrated that MPEC improves the hospital course of patients with major UGI bleeding due to Mallory-Weiss tear. However, hospital deaths were reported in 13% of the control cases with Mallory-Weiss tears. Because the patients in the present study were not randomized to receive endoscopic versus sham therapy, a definitive conclusion as to the benefit of hemoclipping is not possible. It is necessary to establish criteria for endoscopic hemoclipping in MWS patients with active bleeding (spurting, streaming or oozing) or without active bleeding (visible vessels or fresh adherent clots). However, controlled trials have risk for MWS patients with bleeding, as is clear from Laine’s data on hospital deaths. The present study shows that hemoclipping is safe, easy and effective, even in cases with active bleeding or stigmata of recent bleeding. Hemoclips did not impair the healing of MWS tears, even when the hemoclips were retained for prolonged periods. It appears that endoscopic hemoclipping for any stigmata of MWS bleeding is worthwhile and not harmful. REFERENCES 1. Mallory GK, Weiss S. Hemorrhages from laceration of cardia orifice of the stomach due to vomiting. Am J Med Sci 1929;178:506-10. 2. Sugawa C, Steffes CP, Nakamura R, Sferra JJ, Sferra CS, Sugimura Y, et al. Upper GI bleeding in an urban hospital: etiology, recurrence, and prognosis. Ann Surg 1990;212:521-7. 3. Bratus VD, Fomin PD, Utratin GA, Fedorov EA, Osingol’ts SL. Emergency diagnosis and surgical treatment of acute gastric hemorrhage in the Mallory-Weiss syndrome. Vestn Khir 1986;137:26-30. 4. Jensen DM, Kovacs TOG, Machicado GA, Randall GM, Sue M. Prospective study of the stigmata of hemorrhage and endoscopic and medical treatment of bleeding Mallory-Weiss tears [abstract]. Gastrointest Endosc 1992;38:AB39. 5. Caroli A, Follador R, Gobbi V, Breda P, Ricci G. Mallory-Weiss syndrome: personal experience and review of the literature. Minerva Gastroenterol Dietol 1989;35:7-12. 6. Bubrick MP, Lundeen JW, Onstad GR, Hitchcock CR. Mallory-Weiss syndrome: analysis of fifty-nine cases. Surgery 1980;88:400-5. GASTROINTESTINAL ENDOSCOPY
429
Y Yamaguchi, T Yamato, N Katsumi, et al.
7. Sugawa C, Benishek D, Walt AJ. Mallory-Weiss syndrome. Am J Surg 1983;145:30-3. 8. Hasting PR, Peters KW, Cohn I Jr. Mallory-Weiss syndrome. Am J Surg 1981;142:560-6. 9. Welch GH, McArdle CS, Anderson JR. Balloon tamponade for the control of Mallory-Weiss syndrome in patients with coagulation defects. Br J Surg 1987;74:610-1. 10. Di Felice G. The current role of endoscopy in Mallory-Weiss syndrome. Surg Endosc 1991;11:879-83. 11. Sugawa C, Fujita Y, Ikeda T, Walt AJ. Endoscopic hemostasis of bleeding of the upper gastrointestinal tract by local injection of ninety-eight percent dehydrated ethanol. Surg Gynecol Obstet 1986;162:159-63. 12. Laine L. Multipolar electrocoagulation versus injection therapy in the treatment of bleeding peptic ulcers: a prospective, randomized trial. Gastroenterology 1990;99:1303-6. 13. Konigsrainer A, Sandbichler P, Aigner F, Pernthaler H, Pointner R. Endoscopic sclerotherapy of bleeding MalloryWeiss mucosal tear. Wien Klin Wochenschr 1989;101:734-5. 14. Cook DJ, Guyatt GH, Salena BJ, Laine LA. Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology 1992;102:139-48. 15. Bataller R, Llach J, Salmeron JM, Elizalde JI, Mas A, Pique JM, et al. Endoscopic sclerotherapy in upper gastrointestinal bleeding due to the Mallory-Weiss syndrome. Am J Gastroenterol 1994;89:2147-50.
Endoscopic hemoclipping for bleeding Mallory-Weiss tears
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Submission of ACCEPTED manuscript on diskette Gastointestinal Endoscopy strongly encourages the submission of final manuscripts on disk. Although files created with WordPerfect are preferred, please send your final manuscript in any electronic format. On your disk, please indicate computer system (e.g., IBM, MacIntosh) and word processing software used (e.g., WordPerfect 6.1).
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