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Mallory–Weiss syndrome: Clinical and endoscopic characteristics
European Journal of Internal Medicine 23 (2012) e92–e96
Contents lists available at SciVerse ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Original article
Mallory–Weiss syndrome: Clinical and endoscopic characteristics Anning Yin a,⁎, 1, Yi Li b, 1, Yingan Jiang a, Jun Liu a, Hesheng Luo a a b
Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
a r t i c l e
i n f o
Article history: Received 8 December 2011 Received in revised form 7 February 2012 Accepted 8 February 2012 Available online 4 March 2012 Keywords: Mallory–Weiss syndrome Clinical characteristics Endoscopic characteristics Upper gastrointestinal bleeding Non-variceal bleeding Hematemesis
a b s t r a c t 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. Crown Copyright © 2012 Published by Elsevier B.V. on behalf of European Federation of Internal Medicine. All rights reserved.
1. Introduction Mallory–Weiss syndrome, first described in 1929, is defined by upper gastrointestinal bleeding from vomiting-induced mucosal lacerations at the esophago-gastric junction [1]. Mallory–Weiss syndrome has been reported to be the cause of upper gastrointestinal bleeding in approximately 3% to 15% of all cases [2–4]. Most of the time, the hemorrhage in Mallory–Weiss syndrome is mild and self-limited, which patients can benefit from conservative medical treatment (including fasting, bed rest, antiemetic, sedation, giving intravenous antacids and somatostatin, and blood transfusion). However, some patients, especially those with risk factors such as evidence of active bleeding (for example, fresh blood hematemesis and hemodynamic instability), presence of stigmata of recurrent bleeding (such as visible vessel and adherent clots) and comorbid diseases (such as hepatic cirrhosis and diabetes mellitus), may require interventional endoscopy and/or other hemostasis procedures [5,6].
⁎ Corresponding author at: Department of Gastroenterology, Renmin Hospital of Wuhan University, Jiefang Road 238, Wuhan, 430060, Hubei, People's Republic of China. Tel./fax: + 86 27 88041911. E-mail address: [email protected] (A. Yin). 1 Contributed to this study as co-first authors.
Surgery, balloon tamponade, transcatheter embolization techniques, and systemic or selective arterial infusion of vasopressin have been used to control active bleeding in patients with Mallory–Weiss syndrome [7–9]. Various endoscopic techniques, such as multipolar electrocoagulation [10,11], endoscopic injection therapy [12–14], endoscopic hemoclipping [13,15,16], and endoscopic band ligation [17–20], have been used to treat upper gastrointestinal bleeding caused by Mallory–Weiss syndrome. Although studies on the management and long-term outcome of Mallory–Weiss syndrome have been widely documented, Mallory– Weiss syndrome and its clinical characteristics in Chinese patients are poorly understood. In this retrospective study, the incidence, location, clinical manifestation, diagnosis, and effectiveness of treatment (including endoscopic treatment and conservative medical treatment) on Mallory–Weiss syndrome were investigated in Renmin Hospital of Wuhan University, with the aim of presenting experience on diagnosis and treatment of Mallory–Weiss syndrome in China. 2. Methods From September 2007 to August 2011, sixteen patients with an endoscopically confirmed Mallory–Weiss syndrome were considered for inclusion in the study. The patients were hospitalized and underwent
0953-6205/$ – see front matter. Crown Copyright © 2012 Published by Elsevier B.V. on behalf of European Federation of Internal Medicine. All rights reserved. doi:10.1016/j.ejim.2012.02.005
A. Yin et al. / European Journal of Internal Medicine 23 (2012) e92–e96
endoscopy within 12 h of admission in gastrointestinal endoscopy center of Renmin Hospital of Wuhan University. Mallory–Weiss syndrome is defined [19] as a mucosal tear or laceration near the esophagogastric junction with active hemorrhage (spurting or oozing), or stigmata of recent hemorrhage (visible vessel or adherent clot or dark base), or lesions without active hemorrhage. Hemodynamic instability was defined as meeting one or more of the following criteria: systolic blood pressure of less than 90 mm Hg and pulse rate greater than 100 beats per min, accompanied by pallor and/or cold sweating, coagulopathy or bleeding diathesis defined as a prothrombin time of greater than 14.5 s (normal 11–13 s) and/or a platelet count less than 60,000 per mm3 (normal 130,000–490, 000) [6,21]. Conservative medical treatment to Mallory–Weiss syndrome, mainly includes fasting (at least 48–72 h), bed rest, antiemetic (metoclopramide, 10 mg, intramuscular), sedation (diazepam, 5–10 mg, intramuscular), giving proton-pump inhibitors (omeprazole, 40 mg, q12h-q8h) and somatostatin (250 μg/h), and blood transfusion (hemoglobin level was less than 70 g/L) [22,23]. Endoscopies were performed with Olympus video-endoscope after hemodynamic support treatment including intravenous fluids and blood transfusion if necessary. All endoscopic procedures were performed by members of the research team, which consisted of 6 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 two or more members of the research team were sought during emergency endoscopy. The forward-viewing endoscope (XQ240, Q240 and Q260; Olympus, Tokyo, Japan) was used in endoscopic examinations. Local injection was performed with an adrenaline solution 1:10,000 in four-quadrant fashion. Multipolar electrocoagulation was performed using a 10F Gold Probe (Microvasive, Natick, Massachusetts, USA) and a 60 W energy source (ERBE USA Inc., Marietta, Georgia, USA) at a setting of 20 W and continuous power were provided. Hemoclips (HX-600-135,135S hemoclip; Olympus Optical, Tokyo, Japan) were applied with a rotatable clip-fixing device (HX-6UR-1) by using an endoscope with a 3.2 mm diameter accessory channel. Endoscopic band ligation was performed with a pneumoactive single-band ligator (Sumitomo Bakelite, Tokyo, Japan) according to the manufacturer's instructions. Primary hemostasis was defined as endoscopically verified cessation of bleeding after endoscopic treatment (including hemoclipping or local injection or multipolar electrocoagulation) or conservative medical treatment within 24 h of admission. For those patients with endoscopic hemostasis they were given intravenous antacids of proton pump inhibitors for 48 h. Hemoglobin concentration of the patients was monitored daily, and blood transfusions were applied for patients whose hemoglobin level was less than 70 g/L. Rebleeding was defined as follows: (i) confirmation of bleeding at follow-up endoscopy; and (ii) fresh hematemesis and/or melena accompanied by either shock or a fall in hemoglobin levels greater than 20 g/L within a 24 h period. The clinical manifestation, medical history, location and characteristics of Mallory–Weiss syndrome, methods and effectiveness of therapy (including endoscopic treatment and conservative medical treatment) of those patients were retrospectively analyzed by chart reviews. Longterm follow-up data were collected at outpatient clinics or by telephone interviews. Informed consent was obtained from all patients before enrollment, and this research was approved by the Ethics Committee of Renmin Hospital of Wuhan University, carried out in accordance with the Helsinki Declaration as revised in 1989. 3. Results Sixteen out of 519 patients with acute non-variceal upper gastrointestinal bleeding were diagnosed as Mallory–Weiss syndrome from September 2007 to August 2011 at gastrointestinal endoscopy center of Renmin Hospital of Wuhan University, which accounted for 3.08%
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of the sources of bleeding in acute non-variceal upper gastrointestinal bleeding. The clinical manifestation and endoscopy diagnosis of Mallory–Weiss syndrome are listed in Table 1. Endoscopy treatment or conservative medical treatment, and its outcome of Mallory–Weiss syndrome are listed in Table 2. The median age was 43.3 years, ranging from 19 to 78 years. Most patients presented with melena and/or hematemesis while 2 male, 54-year-old and 61-year-old patients presented (Patients No.7 and No.14) with only retch or stomachache without external signs of bleeding. And one male patient, 78-year-old (Patient No.6) had a previous history of hepatic cirrhosis. No other common comorbidity causes for Mallory–Weiss syndrome were found in other patients. No patients were receiving anticoagulant therapy, platelet aggregation inhibitors, or non-steroidal anti-inflammatory drug medication. Six patients (Patients No.1, No.5, No.6, No.12, No.15, and No.16) presented with hemodynamic instability and needed blood transfusion before endoscopy. Active hemorrhage or stigmata of recent hemorrhage was detected during first endoscopy in nine patients. Lesions without active hemorrhage were detected in seven patients, which received conservative medical treatment and primary hemostasis was all achieved. One patient failed to establish diagnosis of Mallory–Weiss syndrome during first endoscopy and needed more than one endoscopy to achieve conclusive diagnosis and exact location of Mallory–Weiss syndrome. The most frequent location was the cardia (10/16, 62.5%), followed by the esophagus-cardia (4/16, 25.0%), and esophagus (2/16, 12.5%). And four endoscopic techniques were used: (1) only multipolar electrocoagulation in 1 case; (2) hemoclipping in 5 cases; (3) hemoclipping plus endoscopic band ligation in 1 case; and (4) injection therapy in 3 cases. Primary hemostasis was achieved in 14 patients. No endoscopic complications were found. Recurrent bleeding was detected in 2 patients (Patients Nos. 6 and 15) within 24 h. Patient No.6 (78-year-old, male), had a previous history of hepatic cirrhosis for more than 10 years because of alcoholic hepatitis. Liver function of Patient No.6 is abnormal, including level of ALT, albumin, bilirubin, and APTT. Blood transfusion (including red blood cells and plasma) before endoscopy is needed because of hemodynamic instability and coagulation. The location, stigmata (Forrest), and number of tear of Patient No.6 is cardia,Ia and two. Primary hemostasis of Patient No.6 was failure in the first endoscopy. So hemoclipping plus endoscopic band ligation was placed during the second endoscopy. After that, surgery was selected due to uncontrolled bleeding during the third episode. But the patient died of liver failure 3 days after surgery. Blood transfusion of Patient No.15 (38-year-old, female) before endoscopy is also needed because of hemodynamic instability. The location, stigmata (Forrest), and number of tear of Patient No.15 are cardia,Ib and two. Primary hemostasis of Patient No.15 was failure in the first endoscopy. And the second endoscopy treatment was not implemented because of objection of the family. After that, surgical intervention was taken after active bleeding was not to be controlled with hemoclipping because of the family request. Follow-up of the Patient No.15 was 31 months, and no recurrent bleeding was noted. Follow-up was conducted in 15 patients, ranging from 7 to 51 months after effective treatment. No recurrent bleeding was noted in all patients. 4. Discussion Mallory–Weiss syndrome is one cause of non-variceal upper gastrointestinal hemorrhage, accounting for 3% to 15% of cases [2]. Kim et al. reported that the frequency is 6.68% (159/2379) in Korea [24]. Yamaguchi et al. found the incidence rate is 5.36% (58/1082) in Spain [16]. In this study, we found that Mallory–Weiss syndrome accounts for 3.08% (16/519) of acute non-variceal upper gastrointestinal bleeding according to a four year retrospectively clinical study in a provincial general hospital in Middle China. This proportion is consistent with other previously published epidemiological series [2–4]. And the frequency of Mallory–Weiss syndrome is 8.82% (6/68) in
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A. Yin et al. / European Journal of Internal Medicine 23 (2012) e92–e96
Table 1 Clinical manifestation and endoscopy diagnosis of MWS. Patient no.
Sex/age (yr)
Clinical manifestation
Location
Stigmata (Forrest)
Number of tear
Hemodynamic instability
Diagnosis at initial endoscopy
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
F/42 M/36 M/53 M/37 M/56 M/78 M/54 F/30 F/42 M/19 M/49 M/30 F/25 M/61 F/38 M/43
Hematemesis Hematemesis Hematemesis Hematemesis Hematemesis/melena Hematemesis Retch Melena Hematemesis/melena Hematemesis Melena Hematemesis/melena Hematemesis Stomachache Hematemesis Hematemesis/melena
Cardia Cardia Cardia Esophagus Esophagus–cardia Cardia Cardia Cardia Esophagus–cardia Esophagus–cardia Cardia Cardia Esophagus Cardia Cardia Esophagus–cardia
IIa III IIb III IIa Ia III IIc III III IIc IIb III III Ib IIa
1 1 1 1 1 2 1 1 1 1 1 1 1 1 2 1
+ − − − + + − − − − − + − − + +
+ + + − + + + + + + + + + + + +
I:Active hemorrhage (Ia: Spurting; Ib: Oozing); II: Stigmata of recent hemorrhage (IIa: Visible vessel; IIb: Adherent clot; IIc: Dark base); III: Lesions without active hemorrhage. For patients who were not diagnosed with MWS during initial endoscopy, the location, number of tear, and stigmata refer to the findings during repeated endoscopy. MWS: Mallory– Weiss syndrome.
non-variceal upper gastrointestinal hemorrhage in the north of China [15]. These indicate that Mallory–Weiss syndrome appears not to be a common source of acute non-variceal upper gastrointestinal bleeding in China or other countries. And we conclude that the hemorrhage can be controlled completely with conservative medical treatment in lesions without active hemorrhage, and endoscopic treatment may be important to primary hemostasis in patients with active hemorrhage or stigmata of recent hemorrhage. Although Mallory–Weiss syndrome is an uncommon cause of nonvariceal gastrointestinal bleeding and generally follows a benign course in more than 90% of the cases, the condition is sometimes associated with a fatal outcome. The following are significant risk factors for mortality in patients with Mallory–Weiss syndrome [25]: advanced age, presence of shock on arrival, low initial and minimum hemoglobin levels, prolonged prothrombin time, high AST and ALT levels, endoscopic findings of exposed vessels, history of rebleeding, high volume of blood transfusion, and the presence of the clinical symptom of a tarry stool. In the study, as active bleeding of Patient No.6 was not be controlled in the first endoscopic treatment, the surgical intervention was not taken immediately because of the previous history of hepatic cirrhosis. After surgery was selected due to uncontrolled bleeding during the third episode, the patient died of liver failure in three days.
Giving intravenous antacids (especially PPIs) is more and more important in the conservative medical treatment to Mallory–Weiss syndrome [26]. Traditionally, antacids have included sucralfate, histamine H2 receptor antagonists (H2RAs), and so on. Sucralfate must be administered intragastrically and is therefore unsuitable for patients in whom a gastric tube cannot be placed. The H2RAs are currently the most widely used agents in prophylactic acid suppression; however, proton pump inhibitors (PPIs), such as esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole, have recently replaced H2RAs in the treatment of many acid-related conditions, including peptic ulcer disease, gastroesophageal reflux disease, GI damage caused by nonsteroidal anti-inflammatory drugs, and Zollinger–Ellison syndrome, etc. PPIs achieve a more rapid and sustained increase in gastric pH and are not associated with the rapid tachyphylaxis seen with H2RAs [27]. Endoscopic treatment is currently recommended as a first-line choice for active bleeding of Mallory–Weiss syndrome. A large variety of hemostasis techniques including injection of different agents (such as epinephrine or sclerosant), multipolar electrocoagulation, endoscopic band ligation, endoscopic hemoclipping or a combination of those methods have been used for hemostasis of Mallory–Weiss syndrome with permanent hemostasis achieved in more than 90% of patients [10–20]. Endoscopic hemoclipping is emerging as first-line alternative in the endoscopic treatment armamentarium against actively bleeding
Table 2 Endoscopy treatment and outcome of MWS. Patient no.
Endoscopy treatment
Primary hemostasis
Relapse within 24 h
Treatment for relapse
Hemostasis for relapse
Follow-up (mo)
1 2 3 4 5 6
Hemoclipping − Local injection − Hemoclipping Hemoclipping
+ + + + + −
− − − − − +
− − −
− − − − − −
18 24 15 38 41 0
7 8 9 10 11 12 13 14 15 16
− Local injection − − MPEC Local injection − − Hemoclipping Hemoclipping
+ + + + + + + + − +
− − − − − − − − + −
− − − − − − − − − −
46 35 11 9 51 25 7 14 31 27
EBL: endoscopic band ligation; MPEC: multipolar electrocoagulation.
− 2nd: Hemoclipping + EBL 3rd: Surgery − − − − − − − Surgery −
A. Yin et al. / European Journal of Internal Medicine 23 (2012) e92–e96
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Fig. 1. Treatment algorithm for patients with Mallory–Weiss syndrome.
Mallory–Weiss syndrome. Yamaguchi et al. [16] reported 26 patients in whom hemoclipping was technically successful and hemostasis was achieved in all without recurrence of bleeding. In a prospective randomized clinical trial, Huang et al. [12] compared the efficacy and safety of hemoclip placement with endoscopic epinephrine injection in actively bleeding lesions. They concluded based on 35 patients studied that either method used is equally safe and effective for control of bleeding, spurting, or oozing lesions. Shimoda et al. [28] reported that application of hemoclips was effective for bleeding Mallory–Weiss syndrome during endoscopic procedures, which warranted prophylactic application of hemoclips on Mallory–Weiss syndrome during endoscopic examination. The iatrogenic causes of Mallory–Weiss syndrome are mainly endoscopic procedures. Endoscopic band ligation is another first-line procedure in active bleeding of Mallory–Weiss syndrome. In a prospective randomized study, Cho et al. [29] reported that endoscopic hemoclipping and endoscopic band ligation 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. Therefore, either treatment modality can be used as a first-line therapy with actively bleeding Mallory–Weiss syndrome. Lecleire et al. [30] compared the efficacy of endoscopic band ligation vs. hemoclip plus epinephrine (adrenaline) in bleeding Mallory–Weiss syndrome in 218 consecutive patients from 2001 to 2008. They concluded that this is the first time that band ligation is proved to decrease the rebleeding rate as compared with hemoclip placement combined with epinephrine injection. In summary, the results of the present study indicate that Mallory– Weiss syndrome, as an uncommon cause, accounts for 3.08% of the instances of non-variceal upper gastrointestinal bleeding in Middle China. An algorithm (Fig. 1) of the management of Mallory–Weiss syndrome particularly during acute presentation of bleeding according to our experience and recent publications on the treatment of Mallory– Weiss syndrome is made. Endoscopic treatment proved to be safe and effective in controlling active hemorrhage or stigmata of recent hemorrhage from Mallory–Weiss syndrome. Better options and approaches should be explored for identifying the location of Mallory–Weiss syndrome which are difficult to define and refractory to routine endoscopy techniques. Given the retrospective design of our study, these results require further prospective assessment. 5. 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. 6. Study limitation Overall, our study included only a small group of Chinese patients, and a future study with a large cohort will be needed. Learning points • 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. Conflict of interest statement No funding or grant was received by any author for this work. Neither author has any commercial or proprietary interest in any drug, device, or equipment mentioned in the submitted article. Neither author has any financial interest (as a consultant, stock owner, employee, evaluator, etc) in any item mentioned in the article. The authors stated that they have no interests which might be perceived as posing a conflict or bias. 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] Church NI, Palmer KR. Ulcers and nonvariceal bleeding. Endoscopy 2003;35:22–6. [3] Di Fiore F, Lecleire S, Merle V, Hervé S, Duhamel C, Dupas JL, et al. Changes in characteristics and outcome of acute upper gastrointestinal haemorrhage: a comparison of epidemiology and practices between 1996 and 2000 in a multicentre French study. Eur J Gastroenterol Hepatol 2005;17:641–7. [4] Lecleire S, Di Fiore F, Merle V, Hervé S, Duhamel C, Rudelli A, et al. Acute upper gastrointestinal bleeding in patients with liver cirrhosis and in noncirrhotic patients: epidemiology and predictive factors of mortality in a prospective multicenter population-based study. J Clin Gastroenterol 2005;39:321–7. [5] Terada R, Ito S, Akama F, Kidogawa H, Kashima K, Yamayoshi T, et al. Mallory– Weiss syndrome with severe bleeding: treatment by endoscopic ligation. Am J Emerg Med 2000;18:812–5. [6] Kortas DY, Haas LS, Simpson WG, Nickl NJ, Gates Jr LK. Mallory–Weiss tear: predisposing factors and predictors of a complicated course. Am J Gastroenterol 2001;96:2863–5. [7] Sugawa C, Benishek D, Walt AJ. Mallory–Weiss syndrome. Am J Surg 1983;145: 30–3. [8] Hasting PR, Peters KW, Cohn Jr I. Mallory–Weiss syndrome. Am J Surg 1981;142: 560–6.
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[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] Levenson SD, Koch J, Cello JP. Mallory–Weiss tear impact of endoscopic therapy. Gastrointest Endosc 1993;39:282. [11] Rösch J, Keller FS, Kozak B, Niles N, Dotter CT. Gelfoam powder embolization of the left gastric artery in treatment of massive small-vessel gastric bleeding. Radiology 1984;151:365–70. [12] Huang SP, Wang HP, Lee YC, Lin CC, Yang CS, Wu MS, et al. Endoscopic hemoclip placement and epinephrine injection for Mallory–Weiss syndrome with active bleeding. Gastrointest Endosc 2002;55:842–6. [13] Chung IK, Kim EJ, Hwang KY, Kim IH, Kim HS, Park SH, et al. Evaluation of endoscopic hemostasis in upper gastrointestinal bleeding related to Mallory–Weiss syndrome. Endoscopy 2002;34:474–9. [14] von Delius S, Thies P, Umgelter A, Prinz C, Schmid RM, Huber W. Hemodynamics after endoscopic submucosal injection of epinephrine in patients with nonvariceal upper gastrointestinal bleeding: a matter of concern. Endoscopy 2006;38: 1284–8. [15] Guo SB, Gong AX, Leng J, Ma J, Ge LM. Application of endoscopic hemoclips for nonvariceal bleeding in the upper gastrointestinal tract. World J Gastroenterol 2009;15:4322–6. [16] Yamaguchi Y, Yamato T, Katsumi N, Morozumi K, Abe T, Ishida H, et al. Endoscopic hemoclipping for upper GI bleeding due to Mallory–Weiss syndrome. Gastrointest Endosc 2001;53:427–30. [17] Matsui S, Kamisako T, Kudo M, Inoue R. Endoscopic band ligation for control of nonvariceal upper GI hemorrhage: comparison with bipolar electrocoagulation. Gastrointest Endosc 2002;55:214–8. [18] Higuchi N, Akahoshi K, Sumida Y, Kubokawa M, Motomura Y, Kimura M, et al. Endoscopic band ligation therapy for upper gastrointestinal bleeding related to Mallory–Weiss syndrome. Surg Endosc 2006;20:1431–4.
[19] Park CH, Min SW, Sohn YH, Lee WS, Joo YE, Kim HS, et al. A prospective, randomized trial of endoscopic band ligation vs. epinephrine injection for actively bleeding Mallory–Weiss syndrome. Gastrointest Endosc 2004;60:22–7. [20] Myung SJ, Kim HR, Moon YS. Severe Mallory–Weiss tear after endoscopy treated by endoscopic band ligation. Gastrointest Endosc 2000;52:99–101. [21] Bharucha AE, Gostout CJ, Balm RK. Clinical and endoscopic risk factors in the Mallory–Weiss syndrome. Am J Gastroenterol 1997;92:805–8. [22] Craddock DR, Logan A, Mayell M. Traumatic rupture of the oesophagus and stomach. Thorax 1968;23:657–62. [23] Beumer JD, Devitt PG, Thompson SK. Intramural oesophageal dissection. ANZ J Surg 2010;80:91–5. [24] Kim JW, Kim HS, Byun JW, Won CS, Jee MG, Park YS, et al. Predictive factors of recurrent bleeding in Mallory–Weiss syndrome. Korean J Gastroenterol 2005;46:447–54. [25] Fujisawa N, Inamori M, Sekino Y, Akimoto K, Iida H, Takahata A, et al. Risk factors for mortality in patients with Mallory–Weiss syndrome. Hepatogastroenterology 2011;58:417–20. [26] Brett S. Science review: the use of proton pump inhibitors for gastric acid suppression in critical illness. Crit Care 2005;9:45–50. [27] Blume H, Donath F, Warnke A, Schug BS. Pharmacokinetic drug interaction profiles of proton pump inhibitors. Drug Saf 2006;29:769–84. [28] Shimoda R, Iwakiri R, Sakata H, Ogata S, Ootani H, Sakata Y, et al. Endoscopic hemostasis with metallic hemoclips for iatrogenic Mallory–Weiss tear caused by endoscopic examination. Dig Endosc 2009;21:20–3. [29] Cho YS, Chae HS, Kim HK, Kim JS, Kim BW, Kim SS, et al. Endoscopic band ligation and endoscopic hemoclip placement for patients with Mallory–Weiss syndrome and active bleeding. World J Gastroenterol 2008 Apr 7;14:2080–4. [30] Lecleire S, Antonietti M, Iwanicki-Caron I, Duclos A, Ramirez S, Ben-Soussan E, et al. Endoscopic band ligation could decrease recurrent bleeding in Mallory– Weiss syndrome as compared to haemostasis by hemoclips plus epinephrine. Aliment Pharmacol Ther 2009;30:399–405.
Contents lists available at SciVerse ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Original article
Mallory–Weiss syndrome: Clinical and endoscopic characteristics Anning Yin a,⁎, 1, Yi Li b, 1, Yingan Jiang a, Jun Liu a, Hesheng Luo a a b
Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
a r t i c l e
i n f o
Article history: Received 8 December 2011 Received in revised form 7 February 2012 Accepted 8 February 2012 Available online 4 March 2012 Keywords: Mallory–Weiss syndrome Clinical characteristics Endoscopic characteristics Upper gastrointestinal bleeding Non-variceal bleeding Hematemesis
a b s t r a c t 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. Crown Copyright © 2012 Published by Elsevier B.V. on behalf of European Federation of Internal Medicine. All rights reserved.
1. Introduction Mallory–Weiss syndrome, first described in 1929, is defined by upper gastrointestinal bleeding from vomiting-induced mucosal lacerations at the esophago-gastric junction [1]. Mallory–Weiss syndrome has been reported to be the cause of upper gastrointestinal bleeding in approximately 3% to 15% of all cases [2–4]. Most of the time, the hemorrhage in Mallory–Weiss syndrome is mild and self-limited, which patients can benefit from conservative medical treatment (including fasting, bed rest, antiemetic, sedation, giving intravenous antacids and somatostatin, and blood transfusion). However, some patients, especially those with risk factors such as evidence of active bleeding (for example, fresh blood hematemesis and hemodynamic instability), presence of stigmata of recurrent bleeding (such as visible vessel and adherent clots) and comorbid diseases (such as hepatic cirrhosis and diabetes mellitus), may require interventional endoscopy and/or other hemostasis procedures [5,6].
⁎ Corresponding author at: Department of Gastroenterology, Renmin Hospital of Wuhan University, Jiefang Road 238, Wuhan, 430060, Hubei, People's Republic of China. Tel./fax: + 86 27 88041911. E-mail address: [email protected] (A. Yin). 1 Contributed to this study as co-first authors.
Surgery, balloon tamponade, transcatheter embolization techniques, and systemic or selective arterial infusion of vasopressin have been used to control active bleeding in patients with Mallory–Weiss syndrome [7–9]. Various endoscopic techniques, such as multipolar electrocoagulation [10,11], endoscopic injection therapy [12–14], endoscopic hemoclipping [13,15,16], and endoscopic band ligation [17–20], have been used to treat upper gastrointestinal bleeding caused by Mallory–Weiss syndrome. Although studies on the management and long-term outcome of Mallory–Weiss syndrome have been widely documented, Mallory– Weiss syndrome and its clinical characteristics in Chinese patients are poorly understood. In this retrospective study, the incidence, location, clinical manifestation, diagnosis, and effectiveness of treatment (including endoscopic treatment and conservative medical treatment) on Mallory–Weiss syndrome were investigated in Renmin Hospital of Wuhan University, with the aim of presenting experience on diagnosis and treatment of Mallory–Weiss syndrome in China. 2. Methods From September 2007 to August 2011, sixteen patients with an endoscopically confirmed Mallory–Weiss syndrome were considered for inclusion in the study. The patients were hospitalized and underwent
0953-6205/$ – see front matter. Crown Copyright © 2012 Published by Elsevier B.V. on behalf of European Federation of Internal Medicine. All rights reserved. doi:10.1016/j.ejim.2012.02.005
A. Yin et al. / European Journal of Internal Medicine 23 (2012) e92–e96
endoscopy within 12 h of admission in gastrointestinal endoscopy center of Renmin Hospital of Wuhan University. Mallory–Weiss syndrome is defined [19] as a mucosal tear or laceration near the esophagogastric junction with active hemorrhage (spurting or oozing), or stigmata of recent hemorrhage (visible vessel or adherent clot or dark base), or lesions without active hemorrhage. Hemodynamic instability was defined as meeting one or more of the following criteria: systolic blood pressure of less than 90 mm Hg and pulse rate greater than 100 beats per min, accompanied by pallor and/or cold sweating, coagulopathy or bleeding diathesis defined as a prothrombin time of greater than 14.5 s (normal 11–13 s) and/or a platelet count less than 60,000 per mm3 (normal 130,000–490, 000) [6,21]. Conservative medical treatment to Mallory–Weiss syndrome, mainly includes fasting (at least 48–72 h), bed rest, antiemetic (metoclopramide, 10 mg, intramuscular), sedation (diazepam, 5–10 mg, intramuscular), giving proton-pump inhibitors (omeprazole, 40 mg, q12h-q8h) and somatostatin (250 μg/h), and blood transfusion (hemoglobin level was less than 70 g/L) [22,23]. Endoscopies were performed with Olympus video-endoscope after hemodynamic support treatment including intravenous fluids and blood transfusion if necessary. All endoscopic procedures were performed by members of the research team, which consisted of 6 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 two or more members of the research team were sought during emergency endoscopy. The forward-viewing endoscope (XQ240, Q240 and Q260; Olympus, Tokyo, Japan) was used in endoscopic examinations. Local injection was performed with an adrenaline solution 1:10,000 in four-quadrant fashion. Multipolar electrocoagulation was performed using a 10F Gold Probe (Microvasive, Natick, Massachusetts, USA) and a 60 W energy source (ERBE USA Inc., Marietta, Georgia, USA) at a setting of 20 W and continuous power were provided. Hemoclips (HX-600-135,135S hemoclip; Olympus Optical, Tokyo, Japan) were applied with a rotatable clip-fixing device (HX-6UR-1) by using an endoscope with a 3.2 mm diameter accessory channel. Endoscopic band ligation was performed with a pneumoactive single-band ligator (Sumitomo Bakelite, Tokyo, Japan) according to the manufacturer's instructions. Primary hemostasis was defined as endoscopically verified cessation of bleeding after endoscopic treatment (including hemoclipping or local injection or multipolar electrocoagulation) or conservative medical treatment within 24 h of admission. For those patients with endoscopic hemostasis they were given intravenous antacids of proton pump inhibitors for 48 h. Hemoglobin concentration of the patients was monitored daily, and blood transfusions were applied for patients whose hemoglobin level was less than 70 g/L. Rebleeding was defined as follows: (i) confirmation of bleeding at follow-up endoscopy; and (ii) fresh hematemesis and/or melena accompanied by either shock or a fall in hemoglobin levels greater than 20 g/L within a 24 h period. The clinical manifestation, medical history, location and characteristics of Mallory–Weiss syndrome, methods and effectiveness of therapy (including endoscopic treatment and conservative medical treatment) of those patients were retrospectively analyzed by chart reviews. Longterm follow-up data were collected at outpatient clinics or by telephone interviews. Informed consent was obtained from all patients before enrollment, and this research was approved by the Ethics Committee of Renmin Hospital of Wuhan University, carried out in accordance with the Helsinki Declaration as revised in 1989. 3. Results Sixteen out of 519 patients with acute non-variceal upper gastrointestinal bleeding were diagnosed as Mallory–Weiss syndrome from September 2007 to August 2011 at gastrointestinal endoscopy center of Renmin Hospital of Wuhan University, which accounted for 3.08%
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of the sources of bleeding in acute non-variceal upper gastrointestinal bleeding. The clinical manifestation and endoscopy diagnosis of Mallory–Weiss syndrome are listed in Table 1. Endoscopy treatment or conservative medical treatment, and its outcome of Mallory–Weiss syndrome are listed in Table 2. The median age was 43.3 years, ranging from 19 to 78 years. Most patients presented with melena and/or hematemesis while 2 male, 54-year-old and 61-year-old patients presented (Patients No.7 and No.14) with only retch or stomachache without external signs of bleeding. And one male patient, 78-year-old (Patient No.6) had a previous history of hepatic cirrhosis. No other common comorbidity causes for Mallory–Weiss syndrome were found in other patients. No patients were receiving anticoagulant therapy, platelet aggregation inhibitors, or non-steroidal anti-inflammatory drug medication. Six patients (Patients No.1, No.5, No.6, No.12, No.15, and No.16) presented with hemodynamic instability and needed blood transfusion before endoscopy. Active hemorrhage or stigmata of recent hemorrhage was detected during first endoscopy in nine patients. Lesions without active hemorrhage were detected in seven patients, which received conservative medical treatment and primary hemostasis was all achieved. One patient failed to establish diagnosis of Mallory–Weiss syndrome during first endoscopy and needed more than one endoscopy to achieve conclusive diagnosis and exact location of Mallory–Weiss syndrome. The most frequent location was the cardia (10/16, 62.5%), followed by the esophagus-cardia (4/16, 25.0%), and esophagus (2/16, 12.5%). And four endoscopic techniques were used: (1) only multipolar electrocoagulation in 1 case; (2) hemoclipping in 5 cases; (3) hemoclipping plus endoscopic band ligation in 1 case; and (4) injection therapy in 3 cases. Primary hemostasis was achieved in 14 patients. No endoscopic complications were found. Recurrent bleeding was detected in 2 patients (Patients Nos. 6 and 15) within 24 h. Patient No.6 (78-year-old, male), had a previous history of hepatic cirrhosis for more than 10 years because of alcoholic hepatitis. Liver function of Patient No.6 is abnormal, including level of ALT, albumin, bilirubin, and APTT. Blood transfusion (including red blood cells and plasma) before endoscopy is needed because of hemodynamic instability and coagulation. The location, stigmata (Forrest), and number of tear of Patient No.6 is cardia,Ia and two. Primary hemostasis of Patient No.6 was failure in the first endoscopy. So hemoclipping plus endoscopic band ligation was placed during the second endoscopy. After that, surgery was selected due to uncontrolled bleeding during the third episode. But the patient died of liver failure 3 days after surgery. Blood transfusion of Patient No.15 (38-year-old, female) before endoscopy is also needed because of hemodynamic instability. The location, stigmata (Forrest), and number of tear of Patient No.15 are cardia,Ib and two. Primary hemostasis of Patient No.15 was failure in the first endoscopy. And the second endoscopy treatment was not implemented because of objection of the family. After that, surgical intervention was taken after active bleeding was not to be controlled with hemoclipping because of the family request. Follow-up of the Patient No.15 was 31 months, and no recurrent bleeding was noted. Follow-up was conducted in 15 patients, ranging from 7 to 51 months after effective treatment. No recurrent bleeding was noted in all patients. 4. Discussion Mallory–Weiss syndrome is one cause of non-variceal upper gastrointestinal hemorrhage, accounting for 3% to 15% of cases [2]. Kim et al. reported that the frequency is 6.68% (159/2379) in Korea [24]. Yamaguchi et al. found the incidence rate is 5.36% (58/1082) in Spain [16]. In this study, we found that Mallory–Weiss syndrome accounts for 3.08% (16/519) of acute non-variceal upper gastrointestinal bleeding according to a four year retrospectively clinical study in a provincial general hospital in Middle China. This proportion is consistent with other previously published epidemiological series [2–4]. And the frequency of Mallory–Weiss syndrome is 8.82% (6/68) in
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Table 1 Clinical manifestation and endoscopy diagnosis of MWS. Patient no.
Sex/age (yr)
Clinical manifestation
Location
Stigmata (Forrest)
Number of tear
Hemodynamic instability
Diagnosis at initial endoscopy
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
F/42 M/36 M/53 M/37 M/56 M/78 M/54 F/30 F/42 M/19 M/49 M/30 F/25 M/61 F/38 M/43
Hematemesis Hematemesis Hematemesis Hematemesis Hematemesis/melena Hematemesis Retch Melena Hematemesis/melena Hematemesis Melena Hematemesis/melena Hematemesis Stomachache Hematemesis Hematemesis/melena
Cardia Cardia Cardia Esophagus Esophagus–cardia Cardia Cardia Cardia Esophagus–cardia Esophagus–cardia Cardia Cardia Esophagus Cardia Cardia Esophagus–cardia
IIa III IIb III IIa Ia III IIc III III IIc IIb III III Ib IIa
1 1 1 1 1 2 1 1 1 1 1 1 1 1 2 1
+ − − − + + − − − − − + − − + +
+ + + − + + + + + + + + + + + +
I:Active hemorrhage (Ia: Spurting; Ib: Oozing); II: Stigmata of recent hemorrhage (IIa: Visible vessel; IIb: Adherent clot; IIc: Dark base); III: Lesions without active hemorrhage. For patients who were not diagnosed with MWS during initial endoscopy, the location, number of tear, and stigmata refer to the findings during repeated endoscopy. MWS: Mallory– Weiss syndrome.
non-variceal upper gastrointestinal hemorrhage in the north of China [15]. These indicate that Mallory–Weiss syndrome appears not to be a common source of acute non-variceal upper gastrointestinal bleeding in China or other countries. And we conclude that the hemorrhage can be controlled completely with conservative medical treatment in lesions without active hemorrhage, and endoscopic treatment may be important to primary hemostasis in patients with active hemorrhage or stigmata of recent hemorrhage. Although Mallory–Weiss syndrome is an uncommon cause of nonvariceal gastrointestinal bleeding and generally follows a benign course in more than 90% of the cases, the condition is sometimes associated with a fatal outcome. The following are significant risk factors for mortality in patients with Mallory–Weiss syndrome [25]: advanced age, presence of shock on arrival, low initial and minimum hemoglobin levels, prolonged prothrombin time, high AST and ALT levels, endoscopic findings of exposed vessels, history of rebleeding, high volume of blood transfusion, and the presence of the clinical symptom of a tarry stool. In the study, as active bleeding of Patient No.6 was not be controlled in the first endoscopic treatment, the surgical intervention was not taken immediately because of the previous history of hepatic cirrhosis. After surgery was selected due to uncontrolled bleeding during the third episode, the patient died of liver failure in three days.
Giving intravenous antacids (especially PPIs) is more and more important in the conservative medical treatment to Mallory–Weiss syndrome [26]. Traditionally, antacids have included sucralfate, histamine H2 receptor antagonists (H2RAs), and so on. Sucralfate must be administered intragastrically and is therefore unsuitable for patients in whom a gastric tube cannot be placed. The H2RAs are currently the most widely used agents in prophylactic acid suppression; however, proton pump inhibitors (PPIs), such as esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole, have recently replaced H2RAs in the treatment of many acid-related conditions, including peptic ulcer disease, gastroesophageal reflux disease, GI damage caused by nonsteroidal anti-inflammatory drugs, and Zollinger–Ellison syndrome, etc. PPIs achieve a more rapid and sustained increase in gastric pH and are not associated with the rapid tachyphylaxis seen with H2RAs [27]. Endoscopic treatment is currently recommended as a first-line choice for active bleeding of Mallory–Weiss syndrome. A large variety of hemostasis techniques including injection of different agents (such as epinephrine or sclerosant), multipolar electrocoagulation, endoscopic band ligation, endoscopic hemoclipping or a combination of those methods have been used for hemostasis of Mallory–Weiss syndrome with permanent hemostasis achieved in more than 90% of patients [10–20]. Endoscopic hemoclipping is emerging as first-line alternative in the endoscopic treatment armamentarium against actively bleeding
Table 2 Endoscopy treatment and outcome of MWS. Patient no.
Endoscopy treatment
Primary hemostasis
Relapse within 24 h
Treatment for relapse
Hemostasis for relapse
Follow-up (mo)
1 2 3 4 5 6
Hemoclipping − Local injection − Hemoclipping Hemoclipping
+ + + + + −
− − − − − +
− − −
− − − − − −
18 24 15 38 41 0
7 8 9 10 11 12 13 14 15 16
− Local injection − − MPEC Local injection − − Hemoclipping Hemoclipping
+ + + + + + + + − +
− − − − − − − − + −
− − − − − − − − − −
46 35 11 9 51 25 7 14 31 27
EBL: endoscopic band ligation; MPEC: multipolar electrocoagulation.
− 2nd: Hemoclipping + EBL 3rd: Surgery − − − − − − − Surgery −
A. Yin et al. / European Journal of Internal Medicine 23 (2012) e92–e96
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Fig. 1. Treatment algorithm for patients with Mallory–Weiss syndrome.
Mallory–Weiss syndrome. Yamaguchi et al. [16] reported 26 patients in whom hemoclipping was technically successful and hemostasis was achieved in all without recurrence of bleeding. In a prospective randomized clinical trial, Huang et al. [12] compared the efficacy and safety of hemoclip placement with endoscopic epinephrine injection in actively bleeding lesions. They concluded based on 35 patients studied that either method used is equally safe and effective for control of bleeding, spurting, or oozing lesions. Shimoda et al. [28] reported that application of hemoclips was effective for bleeding Mallory–Weiss syndrome during endoscopic procedures, which warranted prophylactic application of hemoclips on Mallory–Weiss syndrome during endoscopic examination. The iatrogenic causes of Mallory–Weiss syndrome are mainly endoscopic procedures. Endoscopic band ligation is another first-line procedure in active bleeding of Mallory–Weiss syndrome. In a prospective randomized study, Cho et al. [29] reported that endoscopic hemoclipping and endoscopic band ligation 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. Therefore, either treatment modality can be used as a first-line therapy with actively bleeding Mallory–Weiss syndrome. Lecleire et al. [30] compared the efficacy of endoscopic band ligation vs. hemoclip plus epinephrine (adrenaline) in bleeding Mallory–Weiss syndrome in 218 consecutive patients from 2001 to 2008. They concluded that this is the first time that band ligation is proved to decrease the rebleeding rate as compared with hemoclip placement combined with epinephrine injection. In summary, the results of the present study indicate that Mallory– Weiss syndrome, as an uncommon cause, accounts for 3.08% of the instances of non-variceal upper gastrointestinal bleeding in Middle China. An algorithm (Fig. 1) of the management of Mallory–Weiss syndrome particularly during acute presentation of bleeding according to our experience and recent publications on the treatment of Mallory– Weiss syndrome is made. Endoscopic treatment proved to be safe and effective in controlling active hemorrhage or stigmata of recent hemorrhage from Mallory–Weiss syndrome. Better options and approaches should be explored for identifying the location of Mallory–Weiss syndrome which are difficult to define and refractory to routine endoscopy techniques. Given the retrospective design of our study, these results require further prospective assessment. 5. 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. 6. Study limitation Overall, our study included only a small group of Chinese patients, and a future study with a large cohort will be needed. Learning points • 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. Conflict of interest statement No funding or grant was received by any author for this work. Neither author has any commercial or proprietary interest in any drug, device, or equipment mentioned in the submitted article. Neither author has any financial interest (as a consultant, stock owner, employee, evaluator, etc) in any item mentioned in the article. The authors stated that they have no interests which might be perceived as posing a conflict or bias. 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] Church NI, Palmer KR. Ulcers and nonvariceal bleeding. Endoscopy 2003;35:22–6. [3] Di Fiore F, Lecleire S, Merle V, Hervé S, Duhamel C, Dupas JL, et al. Changes in characteristics and outcome of acute upper gastrointestinal haemorrhage: a comparison of epidemiology and practices between 1996 and 2000 in a multicentre French study. Eur J Gastroenterol Hepatol 2005;17:641–7. [4] Lecleire S, Di Fiore F, Merle V, Hervé S, Duhamel C, Rudelli A, et al. Acute upper gastrointestinal bleeding in patients with liver cirrhosis and in noncirrhotic patients: epidemiology and predictive factors of mortality in a prospective multicenter population-based study. J Clin Gastroenterol 2005;39:321–7. [5] Terada R, Ito S, Akama F, Kidogawa H, Kashima K, Yamayoshi T, et al. Mallory– Weiss syndrome with severe bleeding: treatment by endoscopic ligation. Am J Emerg Med 2000;18:812–5. [6] Kortas DY, Haas LS, Simpson WG, Nickl NJ, Gates Jr LK. Mallory–Weiss tear: predisposing factors and predictors of a complicated course. Am J Gastroenterol 2001;96:2863–5. [7] Sugawa C, Benishek D, Walt AJ. Mallory–Weiss syndrome. Am J Surg 1983;145: 30–3. [8] Hasting PR, Peters KW, Cohn Jr I. Mallory–Weiss syndrome. Am J Surg 1981;142: 560–6.
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