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Introduction
Mallory-Weiss Syndrome (MWS) is a common cause of non-varical upper-GI bleeding, accounting for 3-15% of all cases.1,2 MWS-related bleeding is usually mild and self limited. Some patients, especially those with stigmata of active bleeding require emergent treatment.3,4,5 Advances in endoscopic hemostasis techniques to treat active or recurrent upper-GI bleeding have lead to the application of electro coagulation,6,7 ethanol or epinephrine injection,8,9 and endoscopic band ligation in the management of MWS-related bleeding.10,11 Endoscopic clip (endoclip) application is a new technique developed for management of gastrointestinal hemorrhage, endoscopic per luminal closure of bowel perforation, and endoscopic mucosal resection (EMR) sites.12,13 We report the successful use of endoscopic hemoclip application in two cases of upper-GI bleeding caused by MWS.
Case Histories
This 67 year old patient presented to our Emergency Department (ED) with a history of acute onset of nausea and vomiting after a church picnic. Vomiting was initially food, followed by bile, dry heaves, and then voluminous bright red blood. The patient was brought to our ED by his spouse. There he was found to be hypotensive with systolic blood pressure of 90 mmHg and tachycardia (110 beats per minute). Intravenous Ondansetron and Lorazepam were administered to control retching. Physical examination was pertinent for diaphoresis, pale appearance for an African American man of 67 years. The abdominal examination was remarkable for hyperactive bowel sounds, midline surgical scar and mild tenderness in the mid epigastrium to palpation. Neck examination remarkable for left lateral neck scar and absence of carotid pulse on same side and prior tracheotomy scar. Rectal examination revealed maroon to black colored melena. Laboratory tests obtained in the ED showed WBC of 4.2 (4.8-10.8 K/Ul), HCT of 24 (37-47%), creatinine of 1.5 (0.6-1.3 mg/dl), BUN 35 (7-18 mg/dl). Baseline HCT was 43.
Significant past surgical history included shrapnel wound to the neck in Viet Nam 1968, requiring emergent tracheotomy. This was complicated by laryngeal stenosis and need for surgical revision. Right rotator cuff repair. In 1998, the patient had unwittingly taken ipecac for “food” poisoning that caused a Mallory Weiss Tear and torrential upper gastrointestinal (UGI) hemorrhage, that required emergent surgical management. His medical history included essential hypertension, prostatism, osteoarthritis, and hypogonadism. Medications included Atenolol, Amlodipine, Testosterone, Terazosin, and Naproxen.
The patient underwent resuscitative measures in our Intensive Care Unit. Intravenous fluids and blood transfusion were administered until blood pressure was stabilized. Intravenous acid suppression with Pantoprazole was initiated and intravenous anti-emetic drugs administered. Esophagogastroduodenoscopy (EGD) was conducted under general anesthesia. Endoscopy revealed active bleeding from two Mallory Weiss Tears (MWT’s), one located just below the squamo-columar junction and the other located on the ipsi-lateral wall of the esophagus just above this (Figures 1, 2). Both MWT’s were oozing blood and contained a central visible vessel (Figure 3). Both of the tears were about 10 mm in length and very deep. Epinephrine 1:10,000 was injected in 0.5 cc aliquots, times 4, around each MWT, effectively drying the endoscopic field. Resolution clips (Boston Scientific, Natick, Massachusetts) were then applied to the distal, proximal, then to the mid portion of each MWT. Application of Resolution clips in this fashion approximated the edges of the MWT, effectively closing the tear and occluding the visible vessel (Figures 4,5,6,7). The patient was maintained on anti-emetic and gastric acid blocking medications for 48 hours and ultimately discharged from the hospital. The patient was seen 1 and 2 months after hospital discharge and experienced no untoward sequella from this endoscopic treatment.
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Figure 3 |
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Figure 7 |
A 46 year old male with history of recurrent solid dysphagia and numerous seasonal allergies, presented to our ED with acute food impaction and hematemesis. The patient had consumed a meal of “tough” fried chicken, followed by acute dysphagia and sensation of impaction. He was unable to swallow water or even saliva. This was followed by recurrent vomiting and eventual regurgitation of the meat bolus and large volume hematemesis. He was brought to our ED by his spouse. Physical examination was pertinent for diaphoresis and palor. Supine blood pressure was 94/50 mmHg with a pulse of 124 beats per minute. The abdominal examination was remarkable for hyperactive bowel sounds, and mild tenderness in the mid epigastrium to palpation. Rectal examination revealed small amount of brown stool. Laboratory tests obtained in the ED showed WBC of 6.5 (4.8-10.8 K/Ul), HCT of 28 (37-47%), creatinine of 1.1(0.6-1.3 mg/dl), BUN 30 (7-18 mg/dl). Baseline HCT was 48.
Significant past medical history included numerous seasonal allergies, elevated cholesterol, labile hypertension that was controlled with diet. Medications included Loratadine, and Simvastatin. He denied prior symptoms of heart burn, but did experience periodic dysphagia to poorly chewed solids for the last several years.
Endoscopy identified a distal esophageal MWT with active bleeding and a visible vessel (Figure 8). Endoscopic treatment with mucosal injection of 1:10,000 epinephrine cleared the field of active bleeding and a Resolution clip was applied to the vessel in the center of the MWT (Figures 9, 10). The patient was monitored in the hospital treated with Pantoprazole and Ondanestron and discharged after 36 hours of hospitalization.
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Figure 8 |
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Figure 10 |
At 3 months, the patient underwent follow up EGD. Esophagus was remarkable for numerous mucosal rings throughout the esophagus, hypotensive lower esophageal sphincter with irregular Z line with a focal erosion, see Figure 11. Mucosal biopsies showed > 25 eosinophils per high power field from the esophagus. This patient had findings consistent with both gastroesophaeal reflux disease and eosinophilic esophagitis. He has been treated with one session of esophageal dilation, Omperazole and daily Fluticasone nasal spray. During six months of follow up the patient has not experienced further dysphagia or symptoms of heartburn.
Discussion
Most cases of MWS are associated with mild gastrointestinal bleeding. However our two cases illustrate that when the MWT is deep, life threatening arterial bleeding can occur. In these cases, failure of endoscopic hemostasis will lead to the need for emergent surgery or trans-arterial embolization.1,2,3 In each of the cases of MWS that we report, an actively bleeding vessel was associated with a significant mucosal tear. Our approach to use mucosal injection of epinephrine to slow active bleeding and clear the endoscopic field proved to be a helpful adjunct to facilitate hemoclip application. The Resolution clip (Boston Scientific, Natick, Massachusetts) has several technical features that make the device especially useful in our cases of deep MWT’s. The Resolution clip has a preloaded delivery system that can be passed though a standard 2.8 mm endoscopic operating channel. The 11 mm wide jaw span of the Resolution clip (Figures 12a,12b), was ideal for spanning the width of the mucosal tears seen in each of our patients. The re-opening capability of the Resolution clip (up to 5 times) prior to final deployment, allows precise adjustment and application of the clips in bleeding locations that may be peristaltic, tangential and slippery.
Conclusion
The MWS can be a life threatening condition, requiring prompt resuscitation, emergent therapeutic endoscopy. Combination mucosal injection with epinephrine to slow active bleeding and clear the endoscopic field is a helpful adjunct in the successful application of Resolution clip(s) in these challenging patients.
References
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4.Adler DG, Leighton JA, Davila RE, Hirota WK, Jacobson BC, et al. ASGE guideline: the role of endoscopy in acute non-variceal upper-GI hemorrhage. Gastrointest Endoscopy. 2004;60:497-504.
5. Rockey DC. Gastrointestinal Bleeding. Gastrointestinal Clinics of North Am. 2005;34:581-588.
6. Laine L. Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage. A prospective controlled trial. N Engl J Med. 1987;316:1613-7.
7. Papp JP. Electro coagulation of active bleeding Mallory-Weiss tears. Gastrointest Endosc. 1980;26:128-30.
8. Sugawawa C, Fujita Y, Ikeda T, Walt AJ. Endoscopic hemostasis of upper gastrointestinal tract by local injection of ninety-eight percent dehydrated ethanol. Surg Gynecol Obstet. 1986.162;159-63.
9.Peng YC, Tung CF, Chow WK, Chang CS, Chen GH, Hu WH, et al. Efficacy of endoscopic isotonic saline-epinephrine injection for management of active Mallory-Weiss tears. J Clin Gastroenterol. 2001;32:119-22.
10. Gunay K, Cabioglu N, Barbaros U, Taviloglu K, Ertekin C. Endoscopic ligation for patients with active bleeding Mallory-Weiss tears. Surge Endosc. 2001;15:1305-7.
11. 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 Endoscopy. 2004;60:22-7.
12. Raju GS, Ahmed I, Brining D, Xiao SY. Endoluminal closure of large perforations of colon with clips in a porcine model. Gastroinetst Endosc. 2006;64:640646.
13. Raju GS, Gajula L. Endoclips for GI endoscopy: technical review. Gastrointest Endoscopy. 2004;59267-79.
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