To the Editor:
The Mallory-Weiss syndrome is characterized by bleeding from a mucosal tear of the gastroesophageal junction and may account for an estimated 1%-14% of all upper gastrointestinal bleeding cases.
1
Classically, the syndrome is associated with forceful vomiting or retching before the first episode of hematemesis. The mucosal tear is attributed to shearing forces on the gastroesophageal junction during high intra-abdominal pressures generated by forceful contractions of the diaphragm during vomiting, and less commonly, during severe coughing, status asthmaticus, and generalized convulsion, especially when there is a hiatal hernia.1
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However, some 23% of cases have no identifiable risk factor.1
Here, I describe 3 cases of the Mallory-Weiss syndrome following bouts of severe hiccups.Case Reports
Case 1
A 26-year-old man with a 2-month history of heartburn was otherwise well until he drank 3 bottles of beer, then developed a bout of forceful hiccups, which occurred every few seconds and lasted 3 hours. Then, without prior retching, he vomited approximately 50 cc of bright red blood 4 times. Esophagogastroduodenoscopy revealed a large hiatal hernia containing 3 mucosal lacerations that were not bleeding. His hematemesis ceased; however, his hematocrit decreased 3 percentage points.
Case 2
A 44-year-old man on warfarin anticoagulation therapy developed a bout of intermittent hiccups lasting for 12 hours, which then became forceful and occurred every 1-5 seconds. The next morning, he vomited black emesis and was hospitalized. His examination was unremarkable, but he twice vomited dark blood. Esophagogastroduodenoscopy revealed 2 linear tears containing thrombi in the gastric mucosa of a hiatal hernia. His hematocrit decreased from 43% to 35%, but his bleeding resolved with conservative management.
Case 3
A 57-year-old man with alcoholic cirrhosis developed a 30-minute bout of intense hiccupping, then vomited bright red blood and passed dark red stools. Physical examination was remarkable for hepatosplenomegaly and large-volume ascites. An upper endoscopy revealed a moderate hiatal hernia and an oozing Mallory-Weiss tear. He was given 2 units of packed red blood cells, and he recovered. Over the next 2 months, he was hospitalized 4 more times for hematemesis; each episode was preceded by a bout of intense hiccupping. Endoscopy was not repeated, and his bleeding episodes resolved with conservative management.
Discussion
Only 2 cases of hiccup-associated Mallory-Weiss tears have been reported previously: one was an infant with postprandial hiccups just before hematemesis.
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The second was an adult under anesthesia for a partial gastrectomy and vagectomy, who developed violent hiccups followed by brisk bleeding from a rent in the mucosa of the esophagogastric junction.4
Hiccups are periodic contractions of the diaphragm and, like retching, could exert shear forces on the gastroesophageal junction and tear the mucosa. The 3 patients presented here had severe hiccups just before hematemesis; none had preceding retching or other activity typically associated with Mallory-Weiss tears, and all had hiatal hernias. Although all these patients described intense bouts of hiccups before hematemesis, their physicians, including 3 gastroenterologists, ignored this symptom.
Forceful hiccups may account for some of the cases of Mallory-Weiss tears that lack the typical precipitating factors. Clinicians should solicit a history of hiccups from patients with acute or chronic intestinal bleeding. Perhaps endoscopy could be deferred in stable patients with suspected hiccup-associated Mallory-Weiss syndrome.
References
- Mallory-Weiss tear: predisposing factors and predictors of a complicated course.Am J Gastroenterol. 2001; 96: 2863-2865
- Mucosal tears at the oesophagogastric junction (the Mallory-Weiss syndrome).Gut. 1961; 2: 1-11
- Gastrointestinal hemorrhage due to Mallory-Weiss syndrome in an infant.J Pediatr Gastroenterol Nutr. 1985; 4: 323-324
- Mallory-Weiss syndrome and hypofibrinogenemia complication during surgery.JAMA. 1964; 190: 72-73
Article info
Publication history
Published online: July 29, 2015
Footnotes
Funding: None.
Conflict of Interest: None.
Authorship: All authors had access to the data and a role in writing the manuscript.
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Copyright
© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
