Manner of death determination in a case of gastric mucosal tears.

Gastric tears are rarely described in the forensic pathological literature, although they can lead to a fatal acute exsanguination. Such lesions can arise from several conditions leading to an increased intragastric pressure, such as Mallory Weiss syndrome, cardiopulmonary resuscitation, acute barotrauma and operative procedures, showing peculiar morphological features. We present a case of a 32-year-old drug addicted white woman found dead in a pool of blood in the house of her drug dealer, after taking a dose of intravenous heroin. At autopsy, abundant bloody gastric content and multiple and long gastric tears, extending from the cardias and fundus regions to the gastric corpus were observed; one of them involved the subserous region, resulting in a gastric wall rupture. The victim had no history of recent vomiting and of gastro-intestinal pathologies. Drugs and ethanol levels detected in the specimens of the victim were not consistent with lethal concentrations, thus the death was attributed to acute exsanguination. After reviewing the literature, it turned out that morphological aspects of the gastric tears, such as number, size and topographical distribution, observed at autopsy were atypical compared to those of typical gastric lacerations.

Mallory-Weiss syndrome in four hemodialysis patients: a case study.

BACKGROUND: Hemodialysis patients are prone to gastrointestinal bleeding, and Mallory-Weiss syndrome (MWS) is one of the causes. Mallory-Weiss syndrome is often induced by severe vomiting, manifests as upper gastrointestinal bleeding, and is self-limited with a good prognosis. However, mild vomiting in hemodialysis patients can lead to the occurrence of MWS, and the mild early symptoms are easy to misdiagnose, leading to the aggravation of the disease. CASE PRESENTATION: In this paper, we report four hemodialysis patients with MWS. All patients displayed symptoms of upper gastrointestinal bleeding. The diagnosis of MWS was confirmed by gastroscopy. One patient had a history of severe vomiting; however, the other three reported histories of mild vomiting. Three patients received the conservative hemostasis treatment, and the gastrointestinal bleeding stopped. One patient underwent the gastroscopic and interventional hemostasis treatments. The conditions of three of the patients improved. Unfortunately, one of the patients died due to the cardia insufficiency. CONCLUSIONS: We think that the mild symptoms of MWS are easily covered up by other symptoms. This may lead to delays in diagnosis and treatment. For patients with severe symptoms, gastroscopic hemostasis is still the first choice, and interventional hemostasis can also be considered. For patients with mild symptoms, drug hemostasis is the first consideration.

Rare case of upper gastrointestinal hemorrhage due to accessory spleen: A case report.

RATIONALE: Upper gastrointestinal hemorrhage (UGIH) is defined as hemorrhage originating from the gastrointestinal tract proximal to the ligament of Treitz. The causes of UGIH include esophagitis, gastritis, peptic ulcers, Mallory-Weiss syndrome, and cancer. However, a rare cause of UGIH, such as an accessory spleen, may lead to serious complications if left untreated and can sometimes be very difficult to diagnose preoperatively. PATIENT CONCERNS: An 18-year-old man was admitted to the Department of Gastroenterology of our hospital due to "repeated black stool for 2 months with aggravation, accompanied by hematemesis for 9 days." He denied any history of hepatitis, trauma, or surgery. DIAGNOSIS: Laboratory evaluation revealed severe anemia (hemoglobin, 6.4 g/dL). Computed tomography revealed a mass measuring 127 mm in its largest dimension, located in the upper left abdomen, with varicose veins in the gastric fundus. Moreover, distended blue-purple tortuous veins were observed by gastroscopy in the gastric fundus. We believed the mass was likely an abnormally proliferating accessory spleen; however, the causes of severe anemia and gastrointestinal hemorrhage were unknown. INTERVENTIONS: After discussion in a multidisciplinary conference, the mass was completely resected laparoscopically, and the subserosal veins in the gastric fundus were sutured using absorbable threads. OUTCOMES: After the surgery, the patient recovered uneventfully without any complications. Clinicopathological examination showed that the mass was chronic congestive splenomegaly. Gastrointestinal hemorrhage secondary to an abnormally proliferating accessory spleen was confirmed as the diagnosis. Laboratory evaluation revealed hemoglobin at 12.1 g/dL 2 months after surgery. At the 12-month follow-up, the patient showed no recurrence of gastrointestinal hemorrhage. LESSONS: UGIH caused by accessory spleen is extremely rare. This entity should be considered in differential diagnosis of gastrointestinal hemorrhage. Surgical intervention is necessary for timely diagnosis and treatment in case of gastrointestinal hemorrhage in critical clinical situations.

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

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

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

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

Boerhaave syndrome. Case report and literature review.

Spontaneous lesions can affect only a part of the esophageal wall (Mallory-Weiss syndrome) or constitute a full-thickness rupture of the organ, leading to Boerhaave syndrome. Most commonly affecting males between 50 and 70 years of age, Clinically, the Mackler triad is vomiting, severe chest pain, and subcutaneous cervical emphysema. The delay in diagnosis explains the high mortality rate of this pathology up to 40-60% in those treated at 48 hours. The prognosis improves if treatment is established within the first 24 hours.

Las lesiones espontáneas pueden afectar solo una parte de la pared esofágica (síndrome de Mallory-Weiss) o constituir una rotura de espesor total del órgano, dando lugar al síndrome de Boerhaave. Afecta con mayor frecuencia a los varones entre 50 y 70 años de edad. Clínicamente conforma la tríada de Mackler: vómito, dolor torácico intenso y enfisema subcutáneo cervical. El retraso en el diagnóstico explica su alta tasa de mortalidad, de hasta el 40-60% en los pacientes tratados a las 48 horas. El pronóstico mejora si se logra instaurar el tratamiento dentro de las primeras 24 horas.

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

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

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

[Intra-abdominal bleeding caused after esophagogastroduodenoscopy: a case report].

An 86-year-old man was transferred to the Tokyo Medical University Hospital because of a temporary loss of consciousness and melena. We performed upper gastrointestinal endoscopy, which revealed Mallory-Weiss syndrome caused by a strong vomiting reflex. After an examination, he complained of abdominal pain, and his blood pressure decreased. Abdominal contrast-enhanced computed tomography showed fresh intra-abdominal hemorrhage. We performed transcatheter arterial embolization by using N-butyl-2-cyanoacrylate to control the bleeding from the right gastroepiploic artery. Intra-abdominal hemorrhage after upper gastrointestinal endoscopy is rare, and we report this case with the literature review.

Upper Gastrointestinal Bleeding in Adults: Evaluation and Management.

Upper gastrointestinal (GI) bleeding is defined as hemorrhage from the mouth to the ligament of Treitz. Common risk factors for upper GI bleeding include prior upper GI bleeding, anticoagulant use, high-dose nonsteroidal anti-inflammatory drug use, and older age. Causes of upper GI bleeding include peptic ulcer bleeding, gastritis, esophagitis, variceal bleeding, Mallory-Weiss syndrome, and cancer. Signs and symptoms of upper GI bleeding may include abdominal pain, lightheadedness, dizziness, syncope, hematemesis, and melena. Physical examination includes assessment of hemodynamic stability, presence of abdominal pain or rebound tenderness, and examination of stool color. Laboratory tests should include a complete blood count, basic metabolic panel, coagulation panel, liver tests, and type and crossmatch. A bolus of normal saline or lactated Ringer solution should be rapidly infused to correct hypovolemia and to maintain blood pressure, and blood should be transfused when hemoglobin is less than 7 g per dL. Clinical prediction guides (e.g., Glasgow-Blatchford bleeding score) are necessary for upper GI bleeding risk stratification and to determine therapy. Patients with hemodynamic instability and signs of upper GI bleeding should be offered urgent endoscopy, performed within 24 hours of presentation. A common strategy in patients with failed endoscopic hemostasis is to attempt transcatheter arterial embolization, then proceed to surgery if hemostasis is not obtained. Proton pump inhibitors should be initiated upon presentation with upper GI bleeding. Guidelines recommend high-dose proton pump inhibitor treatment for the first 72 hours post-endoscopy because this is when rebleeding risk is highest. Deciding when to restart antithrombotic therapy after upper GI bleeding is difficult because of lack of sufficient data.

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

BACKGROUND: Adverse events during endoscopic submucosal dissection (ESD) of superficial esophageal neoplasms, such as perforation and bleeding, have been well-documented. However, the Mallory-Weiss Tear (MWT) during esophageal ESD remains under investigation. AIM: To investigate the incidence and risk factors of the MWT during esophageal ESD. METHODS: From June 2014 to July 2017, patients with superficial esophageal neoplasms who received ESD in our institution were retrospectively analyzed. The clinicopathological characteristics of the patients were collected. Patients were divided into an MWT group and non-MWT group based on whether MWT occurred during ESD. The incidence of MWTs was determined, and the risk factors for MWT were then further explored. RESULTS: A total of 337 patients with 373 lesions treated by ESD were analyzed. Twenty patients developed MWTs during ESD (5.4%). Multivariate analysis identified that female sex (OR = 5.36, 95%CI: 1.47-19.50, P = 0.011) and procedure time longer than 88.5 min (OR = 3.953, 95%CI: 1.497-10.417, P = 0.005) were independent risk factors for an MWT during ESD. The cutoff value of the procedure time for an MWT was 88.5 min (sensitivity, 65.0%; specificity, 70.8%). Seven of the MWT patients received endoscopic hemostasis. All patients recovered satisfactorily without surgery for the laceration. CONCLUSION: The incidence of MWTs during esophageal ESD was much higher than expected. Although most cases have a benign course, fatal conditions may occur. We recommend inspection of the stomach during and after the ESD procedure for timely management in cases of bleeding MWTs or even perforation outside of the procedure region.

The prediction value of scoring systems in Mallory-Weiss syndrome patients.

Mallory-Weiss syndrome (MWS) is a relatively less common cause of nonvariceal upper gastrointestinal bleeding. There is limited data on whether scoring systems could be used to predict the clinical outcomes in patients with bleeding due to MWS. The aim of our study is to evaluate whether the Glasgow-Blatchford score (GBS), AIMS65, and shocking index are effective in predicting the clinical outcomes of MWS.One hundred twenty-eight patients from January 2010 to January 2017 with MWS in middle China were enrolled. Clinical features such as age, gender, causes of vomiting, endoscopic findings, GBS, AIMS65, and shocking index were recorded. The clinical outcomes including endoscopic treatment and transfusion were analyzed.MWS accounted for 6.1% of nonvariceal upper gastrointestinal bleeding. Male-to-female ratio was 3.6:1 and median age was 51 years. Patients between 40 and 60 years were more commonly affected; 43.8% of MWS was caused by overdrinking followed by underlying gastric diseases (33.6%). However, for female patients alone, underlying gastric diseases were the leading cause (42.9%). The tears were usually single and most frequently located on the left lateral wall. In receiver-operating characteristic curve analyses, GBS system and shocking index were useful in predicting transfusion (0.856 vs 0.675). But for endoscopic intervention, these scoring systems are not helpful (P > .05).Apart from drinking, underlying gastric disease is another important cause of MWS especially for female patients and should be paid more attention under endoscopy examination. GBS system and shocking index can be used to predict transfusion.

Comparison of risk scores and shock index in hemodynamically stable patients presenting to the emergency department with nonvariceal upper gastrointestinal bleeding.

OBJECTIVE: Risk assessment in nonvariceal upper gastrointestinal bleeding (UGIB) is not well validated and remains unclear in hemodynamically stable patients at emergency department admission. We compared the prognostic value of risk-scoring systems for predicting adverse outcomes in patients with nonvariceal UGIB and normotension. PARTICIPANTS AND METHODS: A single-center prospective observational study was carried out. Patients with consecutive nonvariceal UGIB, presenting with normotension (systolic blood pressure ≥90 mmHg) to the emergency department, were included. We compared the areas under the curves (AUC) of Glasgow Blatchford score (GBS), the pre-endoscopy Rockall score, AIMS65, the shock index, and the modified shock index with respect to adverse outcomes defined as embolization, surgery, ICU admission, rebleeding, and in-hospital mortality. RESULTS: In total, 1233 patients were included. Adverse outcomes occurred in 165 (13.4%) patients; in-hospital mortality was 1.2%. AUC of the GBS for adverse outcome was higher than that of the shock index, but not significantly different (0.647 vs. 0.569, P=0.23). AUC values of the modified shock index, AIMS65, and the pre-endoscopy Rockall score were 0.565, 0.593, and 0.533, respectively. The cut-off value of the GBS (≥8) was associated with 85% sensitivity and 35% specificity for predicting adverse outcome. CONCLUSION: Pre-existing risk scores have shown suboptimal predictive ability for adverse events in normotensive patients with nonvariceal UGIB. The GBS (≥8) might help to identify patients prone to adverse events; however, further studies with risk scores or new scores are needed because of the low accuracy of these scores.

Transition of a Mallory-Weiss syndrome to a Boerhaave syndrome confirmed by anamnestic, necroscopic, and autopsy data: A case report.

RATIONALE: Spontaneous esophageal rupture (Boerhaave syndrome) is a rare, though frequently fatal, event. It is generally caused by a sudden increase in pressure inside the esophagus. In some cases, full-thickness perforations of the esophagus may develop from previous lesions that initially involve only the esophageal mucosa (Mallory-Weiss syndrome) and which, following further triggering events, give rise to a transmural lesion. PATIENT CONCERNS: Here, we present the case of a 45-year-old subject who suddenly died of acute cardio-respiratory failure, an autopsy was performed to identify the cause of death. DIAGNOSIS, INTERVENTIONS, AND OUTCOMES: The autopsy examination revealed a full-thickness rupture of the esophageal wall. Through the integration of necroscopy findings, anamnestic data, and histopathological examination, it has been possible to establish that complete esophageal rupture resulted from the evolution of a previous partial lesion of the esophageal wall, and that an untreated Mallory-Weiss syndrome evolved into a rapidly fatal Boerhaave syndrome. LESSONS: This case shows that distal esophageal tears, rather than constituting a distinct entity, may be part of a spectrum of diseases and that a partial lesion of the esophageal wall caused by barogenic injury may evolve into a full-thickness rupture following further barotraumas.

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

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

Evaluation and management of Non-variceal upper gastrointestinal bleeding.

Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy's lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.

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

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

Comparison of heater probe coagulation and argon plasma coagulation in the management of Mallory-Weiss tears and high-risk ulcer bleeding.

BACKGROUND AND STUDY AIMS: Upper gastrointestinal (GI) bleeding is a common medical emergency. Endoscopic treatments often lead to better therapeutic outcomes than conventional conservative treatments. This study aimed to investigate and compare the use of heater probe coagulation (HPC) and argon plasma coagulation (APC) together with epinephrine injection for the treatment of Mallory-Weiss tears and high-risk ulcer bleeding. PATIENTS AND METHODS: A total of 97 patients (54 in the HPC group and 43 in the APC group) who were diagnosed with upper GI bleeding secondary to a Mallory-Weiss tear or high-risk gastric or duodenal ulcers were included in the study. Lesions were classified according to the Forrest classification. The HPC and APC groups were compared in terms of initial haemostasis, re-bleeding in the early period, need for surgery, average need for transfusion, and duration of hospital stay. RESULTS: There were no significant differences between the HPC and APC groups in terms of ensuring initial haemostasis (98% vs. 97.5%, p>0.05), re-bleeding rates (17% vs. 19%, p>0.05), need for surgery (2% vs. 9%, p>0.05), average need for transfusion (3.7±2.11 vs. 3.4±2.95 units, p>0.05), and average duration of hospital stay (4.6±2.24vs. 5.3±3.23days, p>0.05). CONCLUSION: There was no difference between HPC and APC when used together with epinephrine injection for the treatment of Mallory-Weiss tear and high-risk ulcer bleeding.