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Key Clinical Updates in Benign Esophageal Lesions

The INR does not provide an accurate reflection of coagulopathy in advanced liver disease. Fresh frozen plasma should not be administered routinely in stable patients with an elevated INR because it has no proven benefit but does have potential harms, including increased portal pressures and risk of portal vein or deep venous thrombosis.

Transient elastography (FibroScan) is a noninvasive method for assessing liver stiffness and fibrosis that may be used to stratify patients at high risk for varices (who may benefit from endoscopy) versus those at low risk (in whom endoscopy is not needed).

1. MALLORY-WEISS SYNDROME (MUCOSAL LACERATION OF GASTROESOPHAGEAL JUNCTION)

ESSENTIALS OF DIAGNOSIS

  • Hematemesis; usually self-limited.

  • Prior history of vomiting, retching in 50%.

  • Endoscopy establishes diagnosis.

General Considerations

Mallory-Weiss syndrome is characterized by a nonpenetrating mucosal tear at the gastroesophageal junction that is hypothesized to arise from events that suddenly raise transabdominal pressure, such as lifting, retching, or vomiting (eFigure 15–13). Alcoholism is a strong predisposing factor. Mallory-Weiss tears are responsible for approximately 5% of cases of upper gastrointestinal bleeding.

eFigure 15–13.

A Mallory Weiss tear with active oozing is evident at the squamocolumnar junction. (Used, with permission, from Y. Chen.)

Clinical Findings

A. Symptoms and Signs

Patients usually present with hematemesis with or without melena. A history of retching, vomiting, or straining is obtained in about 50% of cases.

B. Special Examinations

As with other causes of upper gastrointestinal hemorrhage, upper endoscopy should be performed after the patient has been appropriately resuscitated. The diagnosis is established by identification of a 0.5- to 4-cm linear mucosal tear usually located either at the gastroesophageal junction or, more commonly, just below the junction in the gastric mucosa.

Differential Diagnosis

At endoscopy, other potential causes of upper gastrointestinal hemorrhage are found in over 35% of patients with Mallory-Weiss tears, including peptic ulcer disease, erosive gastritis, arteriovenous malformations, and esophageal varices. Patients with underlying portal hypertension are at higher risk for continued or recurrent bleeding.

Treatment

Patients are initially treated as needed with fluid resuscitation and blood transfusions. Most patients stop bleeding spontaneously and require no therapy. Endoscopic hemostatic therapy is employed in patients who have continuing active bleeding. Injection with epinephrine (1:10,000), cautery with a bipolar or heater probe coagulation device, or mechanical compression of the artery by application of an endoclip or band is effective in 90–95% of cases. Angiographic arterial embolization or operative intervention is required in patients who fail endoscopic therapy.

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Corral  JE  et al. Mallory Weiss syndrome is not associated with hiatal hernia: a matched case-control study. Scand J Gastroenterol. ...

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