Endoscopic Band Ligation Could Decrease Recurrent Bleeding in Mallory–Weiss Syndrome as Compared to Haemostasis by Hemoclips Plus Epinephrine

Endoscopic Band Ligation Versus Hemoclips Plus Epinephrine

S. Lecleire, M. Antonietti; I. Iwanicki-Caron; A. Duclos; S. Ramirez; E. Ben-Soussan; S. Hervé; P. Ducrotté

Disclosures

Aliment Pharmacol Ther. 2009;30(4):399-405. 

In This Article

Abstract and Introduction

Abstract

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.

Introduction

Mallory-Weiss syndrome (MWS), first described in 1929, is defined by upper gastrointestinal bleeding (UGIB) from vomiting-induced mucosal lacerations at the oesophago-gastric junction.[1] In recent series, MWS was found to be the aetiology of UGIB in 3 to 10% of cases, even in cirrhotic patients.[2,3] Most of the time, the haemorrhage in MWS is mild, stops spontaneously and patients can benefit from conservative medical management. However, some patients, especially those with stigmata of active bleeding,[4,5] unstable vital signs at admission and/or associated comorbid diseases,[6] may require an haemostasis procedure, which is now best achieved by interventional endoscopy.[7] Indeed, Llach et al. demonstrated that rebleeding occurred significantly more often in patients with a bleeding MWS who did not benefit from an endoscopic haemostasis than in patients who were treated by epinephrine (adrenaline) injection.[8] If an endoscopic haemostasis in bleeding MWS is now recommended, the modalities of the endoscopic procedure are not well-codified and can include epinephrine injection, band ligation, electrocoagulation, hemoclip placement or a combined treatment.[7] The quality of haemostasis observed in bleeding MWS treated by epinephrine injection alone is controversial. First studies showed a primary haemostasis of 100%, but a rebleeding rate of 5.8–44%.[5,9,10] However, Park et al. showed that epinephrine injection and band ligation had the same efficacy with a primary haemostasis of 94% vs. 100% and no observed rebleeding with the two endoscopic procedures.[11] Moreover, hemoclip placement and epinephrine injection were compared in a randomized trial and were equally effective for the primary haemostasis and the rebleeding rate.[9] Recently, Cho et al. compared the efficacy of band ligation and hemoclip placement in patients with bleeding MWS and found that the two procedures were equivalent for primary haemostasis (100%) and rebleeding rate (6% vs. 10%).[12] Two other noncontrolled studies validated the use of hemoclips on one hand and band ligation on the other hand for the treatment of bleeding MWS with a primary haemostasis of 100% except for one patient, and no recurrent bleeding.[13,14] Thus, in literature, hemoclipping and band ligation appear to be safe and effective for the haemostasis of bleeding MWS. The use of epinephrine injection alone could lead to an increased rate of rebleeding, but its use in a combined procedure with hemoclip placement has been extensively described in bleeding peptic ulcer.[15]

As regards the few available studies dealing with the comparison of endoscopic haemostatic procedures in bleeding MWS, we compared the efficacy of band ligation vs. hemoclip placement associated with epinephrine injection in patients presenting with active UGIB caused by a MW tear.

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