Doppler Endoscopic Probe Monitoring of Blood Flow Improves Risk Stratification and Outcomes of Patients With Severe Nonvariceal Upper Gastrointestinal Hemorrhage.

BACKGROUND & AIMS: For 4 decades, stigmata of recent hemorrhage in patients with nonvariceal lesions have been used for risk stratification and endoscopic hemostasis. The arterial blood flow that underlies the stigmata rarely is monitored, but can be used to determine risk for rebleeding. We performed a randomized controlled trial to determine whether Doppler endoscopic probe monitoring of blood flow improves risk stratification and outcomes in patients with severe nonvariceal upper gastrointestinal hemorrhage. METHODS: In a single-blind study performed at 2 referral centers we assigned 148 patients with severe nonvariceal upper gastrointestinal bleeding (125 with ulcers, 19 with Dieulafoy's lesions, and 4 with Mallory Weiss tears) to groups that underwent standard, visually guided endoscopic hemostasis (control, n = 76), or endoscopic hemostasis assisted by Doppler monitoring of blood flow under the stigmata (n = 72). The primary outcome was the rate of rebleeding after 30 days; secondary outcomes were complications, death, and need for transfusions, surgery, or angiography. RESULTS: There was a significant difference in the rates of lesion rebleeding within 30 days of endoscopic hemostasis in the control group (26.3%) vs the Doppler group (11.1%) (P = .0214). The odds ratio for rebleeding with Doppler monitoring was 0.35 (95% confidence interval, 0.143-0.8565) and the number needed to treat was 7. CONCLUSIONS: In a randomized controlled trial of patients with severe upper gastrointestinal hemorrhage from ulcers or other lesions, Doppler probe guided endoscopic hemostasis significantly reduced 30-day rates of rebleeding compared with standard, visually guided hemostasis. Guidelines for nonvariceal gastrointestinal bleeding should incorporate these results. ClinicalTrials.gov no: NCT00732212 (CLIN-013-07F).

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 Associated with Mortality and Increased Drug Costs in Nonvariceal Upper Gastrointestinal Bleeding.

BACKGROUND/AIMS: To determine risk factors associated with mortality and increased drug costs in patients with nonvariceal upper gastrointestinal bleeding. METHODOLOGY: We retrospectively analyzed data from patients hospitalized with nonvariceal upper gastrointestinal bleeding between January 2001-December 2011. Demographic and clinical characteristics and drug costs were documented. Univariate analysis determined possible risk factors for mortality. Statistically significant variables were analyzed using a logistic regression model. Multiple linear regression analyzed factors influencing drug costs. p < 0.05 was considered statistically significant. RESULTS: The study included data from 627 patients. Risk factors associated with increased mortality were age > 60, systolic blood pressure<100 mmHg, lack of endoscopic examination, comorbidities, blood transfusion, and rebleeding. Drug costs were higher in patients with rebleeding, blood transfusion, and prolonged hospital stay. CONCLUSION: In this patient cohort, re-bleeding rate is 11.20% and mortality is 5.74%. The mortality risk in patients with comorbidities was higher than in patients without comorbidities, and was higher in patients requiring blood transfusion than in patients not requiring transfusion. Rebleeding was associ-ated with mortality. Rebleeding, blood transfusion, and prolonged hospital stay were associated with increased drug costs, whereas bleeding from lesions in the esophagus and duodenum was associated with lower drug costs.

Performance of the Glasgow-Blatchford score in predicting clinical outcomes and intervention in hospitalized patients with upper GI bleeding.

BACKGROUND: Data regarding the utility of the Glasgow-Blatchford bleeding score (GBS) in hospitalized patients with upper GI hemorrhage are limited. OBJECTIVE: To evaluate the performance of the GBS in predicting clinical outcomes and the need for interventions in patients with upper GI hemorrhage. DESIGN: Prospective observational study. SETTING: Single, tertiary-care endoscopic center. PATIENTS: Between July 2010 and July 2012, 888 consecutive hospitalized patients managed for upper GI hemorrhage were entered into the study. INTERVENTION: GBS and Rockall scores. MAIN OUTCOME MEASUREMENTS: GBS and Rockall scores were prospectively calculated. The performance of these scores to predict the need for interventions and outcomes was assessed by using a receiver operating characteristic curve. RESULTS: Endoscopy was performed in 708 patients (80%). A total of 286 patients (40.3%) required endoscopic therapy, and 29 patients (3.8%) underwent surgery. GBS and post-endoscopy Rockall scores (post-E RS) were superior to pre-endoscopy Rockall scores in predicting the need for endoscopic therapy (area under the curve [AUC] 0.76 vs 0.76 vs 0.66, respectively) and rebleeding (AUC 0.71 vs 0.64 vs 0.57). The GBS was superior to Rockall scores in predicting the need for blood transfusion (AUC 0.81 vs 0.70 vs 0.68) and surgery (AUC 0.71 vs 0.64 vs 0.51). Patients with GBS scores ≤ 3 did not require intervention. LIMITATIONS: Subjective decision making as to need for endoscopic therapy and blood transfusion. CONCLUSION: Compared with post-E RS, the GBS was superior in predicting the need for blood transfusion and surgery in hospitalized patients with upper GI hemorrhage and was equivalent in predicting the need for endoscopic therapy, rebleeding, and death. There are potential cutoff GBS scores that allow risk stratification for upper GI hemorrhage, which warrant further evaluation.

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.

Natural history of Mallory-Weiss tear in African American and Hispanic patients.

The aim of this study was to determine the natural history of Mallory-Weiss tear (MWT) in African American and Hispanic patients. We retrospectively reviewed medical records of all patients with acute upper gastrointestinal bleeding over a 10-year period. Endoscopic diagnosis of MWT was made in 12% (n = 698) of all patients with acute upper gastrointestinal bleeding. More than half of our patients with MWT did not have a preceding history of retching or vomiting. Bleeding episodes were hemodynamically significant in 216 (31%) patients. Most of the patients with MWT (80%) had an uneventful and short hospital stay (range, 1-4 days). Recurrent upper gastrointestinal bleeding within 30 days occurred in 84 (12%) patients. Overall mortality was 10%; endoscopic hemostasis failure and associated comorbidities were the common culprits.

[Endoscopic methods of hemostasis in treatment of Mallory-Weiss syndrome].

Results of treatment of Mallory-Weiss syndrome using endoscopic methods of hemostasis in 549 patients were analyzed. The patients were divided into two groups: in 2000-2004 years without endoscopic methods, in 2004-2008 years using the endoscopic methods in the diagnostics and treatment. Considerably decreased operative activity and death rate was established in cases of treatment with endoscopic methods.

[Mallory-Weiss lesions]. / Mallory-Weiss laesioner.

INTRODUCTION: Mallory-Weiss syndrome (MW) has been know since 1929. Only few studies exist which focus on the prognosis of the lesion. No Danish MW data are available. The purpose of the study was to describe the demographics of patients admitted with an MW to a Danish surgical unit during a 5-year period and to investigate the prognosis of these patients. MATERIAL AND METHODS: Data from the patient records of 49 patients with endoscopically verified MW admitted through a five-year period were analysed. At follow-up, 35 patients were alive and contacted. A total of 29 responded. The mean time to follow-up from admittance was 42.7 months (range: 10.1-77.1). RESULTS: Haemostasis was achieved in all 49 patients. Sixteen received active therapy during the endoscopic procedure. Haemoglobin at admittance was lower (p = 0.008), the presence of bleeding stigmata higher (p < 0.0001) and the number of patients receiving blood transfusion higher (p = 0.01) among those receiving active therapy than among the group receiving no therapy at the time of their endoscopy. At follow-up, 50% of those receiving active therapy were dead (eight of 16) compared with 18% (six of 33) in the no-therapy group (p = 0.02). In the follow-up period, 10% of the patients admitted with an MW were re-admitted for a new gastrointestinal bleeding. CONCLUSION: Our data suggests that an attitude change is needed toward MW with bleeding stigmata. The course of the disease may not be as benign as generally believed. Further prospective studies designed to resolve this matter are needed.

[Mallory-Weiss syndrome: diagnosis and treatment]. / Syndrome de Mallory-Weiss : diagnostic et traitement.

Mallory-Weiss syndrome is relatively common and is involved in 3 to 10% of cases of upper gastrointestinal bleeding. Most of the time, the hemorrhage is mild and stops spontaneously. Clinical suspicion requires confirmation by an upper gastrointestinal endoscopy, which must be performed rapidly after the first hematemesis. Mallory-Weiss syndrome is diagnosed when it shows a longitudinal mucosal tear at the esophagogastric junction. Patients with active bleeding or signs of recent bleeding at endoscopy need immediate endoscopic treatment for hemostasis. Band ligation seems to be the most efficient procedure for primary hemostasis and for preventing recurrent bleeding. The use of proton pump inhibitors and antiemetics seems logical in all cases, although nothing in the literature demonstrates their efficacy.

Endoscopic hemostasis with metallic hemoclips for iatrogenic Mallory-Weiss tear caused by endoscopic examination.

AIM: Applied endoscopic techniques including mucosal resection, sclerotherapy and endoscopic retrograde cholangiopancreatography (ERCP) have been advanced and iatrogenic complications including Mallory-Weiss tear (MWT) occasionally occur in daily endoscopic procedures. The present study aimed to examine the advantages of clipping for MWT complications that occur during endoscopic examination. METHODS: Over 10 years, we experienced 47 patients with bleeding caused by MWT. Metallic hemoclips were applied for 38 patients for hemostasis. These patients were categorized into two groups: 18 patients in group A whose bleeding tear occurred during endoscopic examination in an iatrogenic condition, and 20 patients in group B visited the emergency unit due to other etiology of MWT. RESULTS: The background characteristics, including length of tears, were not different between the two groups. Initial hemostasis was 100% in groups A and B. Rebleeding was 0/18 (0%) in group A and 1/20 (5 %) in group B. Number of patients who received blood transfusion was significantly higher in group B (group A: 0/18, group B: 4/20). Hemoglobin level before hemostasis was 12.5 g/dL in group A which was not different to that in group B, 10.9 g/dL. CONCLUSION: Application of hemoclips was effective for bleeding MWT during endoscopic procedures, which warranted prophylactic application of hemoclips on MWT during endoscopic examination.

Endoscopic band ligation could decrease recurrent bleeding in Mallory-Weiss syndrome as compared to haemostasis by hemoclips plus epinephrine.

BACKGROUND: Mallory-Weiss syndrome (MWS) with active bleeding at endoscopy may require endoscopic haemostasis the modalities of which are not well-defined. AIM: To compare the efficacy of endoscopic band ligation vs. hemoclip plus epinephrine (adrenaline) in bleeding MWS. METHODS: From 2001 to 2008, 218 consecutive patients with a MWS at endoscopy were hospitalized in our Gastrointestinal Bleeding Unit. In 56 patients (26%), an endoscopic haemostasis was required because of active bleeding. Band ligation was performed in 29 patients (Banding group), while hemoclip application plus epinephrine injection was performed in 27 patients (H&E group). Treatment efficacy and early recurrent bleeding were retrospectively compared between the two groups. RESULTS: Primary endoscopic haemostasis was achieved in all patients. Recurrent bleeding occurred in 0% in Banding group vs. 18% in H&E group (P = 0.02). The use of hemoclips plus epinephrine (OR = 3; 95% CI = 1.15-15.8) and active bleeding at endoscopy (OR = 1.9; 95% CI = 1.04-5.2) were independent predictive factors of early recurrent bleeding. CONCLUSIONS: Haemostasis by hemoclips plus epinephrine was an independent predictive factor of rebleeding. This result suggests that band ligation could be the first choice endoscopic treatment for bleeding MWS, but requires further prospective assessment.

Endoscopic band ligation and endoscopic hemoclip placement for patients with Mallory-Weiss syndrome and active bleeding.

AIM: To compare the hemostatic efficacy and safety of two mechanical endoscopic methods: endoscopic band ligation (EBL) and endoscopic hemoclip placement (EHP) in patients with actively bleeding Mallory-Weiss syndrome (MWS). METHODS: A prospective randomized study to compare the efficacy and safety of EHP with EBL was performed from January 2002 to August 2005. Forty-one patients with active bleeding from MWS were treated with EHP (n = 21) or EBL (n = 20). RESULTS: There were no significant differences between groups with respect to clinical and endoscopic characteristics. The mean number of hemoclips applied was 3.2 +/- 1.5 and the mean number of bands applied was 1.2 +/- 0.4. Primary hemostasis was achieved in all patients. Recurrent bleeding was observed in one patient from the EHP group and two from the EBL group. Patients with recurrent bleeding were treated by the same modality as at randomization and secondary hemostasis was achieved in all. There were no significant differences between the two groups in total transfusion amount or duration of hospital stay. No complications or bleeding-related death resulted. CONCLUSION: EHP and EBL are equally effective and safe for the management of active bleeding in patients with Mallory-Weiss syndrome, even in those with shock or comorbid diseases.

[Mallory-Weiss syndrome after the use of biliary prosthesis]. / Zespól Mallory-Weiss po zastosowaniu protezy dróg zólciowych.

The Mallory-Weiss Syndrome is a rare complication of endoscopic examination. Upper gastrointestinal bleeding due to the Mallory-Weiss Syndrome usually stops spontaneously. The gastroscopy is an effective procedure (method) of diagnosis and treatment of the syndrome. Presented in this paper is a case of 49-year old woman with an upper gastrointestinal bleeding due to the Mallory-Weiss after biliary prosthesis removal. The choledocholithiasis was the primary reason for the initial insertion of prostheses. The cause of gastrointestinal bleeding was determined on the basis of performed gastroscopy in the early stage of prostheses removal forced by bleeding. The bleeding was effectively stopped with endoclips.