今日の臨床サポート

マロリー・ワイス症候群

著者: 高橋信一 立正佼成会附属佼成病院 内科・消化器内科

監修: 上村直実 国立国際医療研究センター 国府台病院

著者校正/監修レビュー済:2020/05/21
患者向け説明資料

概要・推奨   

  1. 再出血の危険性が低く、大量出血ではなく、内視鏡観察時に活動性出血が認められない患者では、短期間の治療でよい(推奨度2)。
  1. 発症の危険因子は飲酒であり、合併症は入院時Ht(ヘマトクリット)の低値と初回内視鏡時の活動性出血を示す症例に多い(推奨度2)。
  1. 内視鏡的止血術は結紮術が第1選択となる(推奨度2)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
高橋信一 : 特に申告事項無し[2021年]
監修:上村直実 : 未申告[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. マロリー・ワイス症候群とは、食道内圧または胃内圧が上昇した結果、食道粘膜が障害されて出血を来した状態のことである。
  1. 激しい嘔吐に伴い、食道・胃接合部に粘膜裂傷を生じ、急性上部消化管出血を来す。
  1. 上部消化管出血の4~14%にみられる。
  1. 男性に多く、30歳~50歳代に好発する。
  1. 腹圧の急激な上昇が誘因であり、大量飲酒後の悪心・嘔吐、激しい咳嗽、妊娠悪阻などで発症する。
  1. 約90%の症例で自然止血がみられ、予後はよく、再発もほとんどみられない。
問診・診察のポイント  
  1. 吐血の前に、腹痛や胃もたれなどの前駆症状がないことを確認する。

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文献 

著者: D Y Kortas, L S Haas, W G Simpson, N J Nickl, L K Gates
雑誌名: Am J Gastroenterol. 2001 Oct;96(10):2863-5. doi: 10.1111/j.1572-0241.2001.04239.x.
Abstract/Text OBJECTIVES: Little has been published regarding predictors of a complicated course after Mallory-Weiss tear (MWT). The aims of this study were to identify risk factors for a Mallory-Weiss tear and factors predictive of a complicated course.
METHODS: At our university hospital, we searched a computerized endoscopy database. At our Veterans Affairs hospital we manually searched printed endoscopy reports. Proposed risk factors for MWT were: history of alcohol use, recent alcohol binge, nonbloody initial emesis, anticoagulation, other coagulopathy, nonsteroidal anti-inflammatory use, and hiatal hernia. Proposed predictors of a complicated course were: age, hematemesis, melena, hematochezia, visible vessel, adherent clot, active bleeding, multiple tears, other pathology at endoscopy, admission Hct, hypotension or orthostatic changes, and coagulopathy. A complicated course was defined on the basis of >6 U of blood transfused, rebleeding, angiography, surgery, or death. Predictors of a complicated course were evaluated using the Mann-Whitney U test or Fisher exact test.
RESULTS: A total of 73 cases were reviewed. The most common risk factor was alcohol use, which was found in 44% of cases. In all, 23% of patients had no risk factors. Of the patients, 17 (23%) had a complicated course. Patients with a complicated course had a lower admission Hct (p = 0.009) and active bleeding at initial endoscopy (p = 0.013).
CONCLUSION: The predictive value of active bleeding supports early endoscopy for stratification and intervention.

PMID 11693318  Am J Gastroenterol. 2001 Oct;96(10):2863-5. doi: 10.111・・・
著者: J Llach, J I Elizalde, M C Guevara, M Pellisé, A Castellot, A Ginès, M T Soria, J M Bordas, J M Piqué
雑誌名: Gastrointest Endosc. 2001 Dec;54(6):679-81.
Abstract/Text BACKGROUND: Endoscopic injection is widely used in the therapy of bleeding gastroduodenal ulcers, but its role in the management of bleeding Mallory-Weiss tears has not been properly assessed.
METHODS: Sixty-three patients undergoing emergency endoscopy in whom there was a high index of suspicion that a Mallory-Weiss tear was the source of bleeding were randomly assigned to undergo endoscopic injection therapy (epinephrine and polidocanol) or no endoscopic therapy in 2 university-affiliated hospitals. Rates of recurrent bleeding, transfusion requirements, complications, mortality, and length of hospital stay were determined for both groups of patients.
RESULTS: Bleeding recurred in 8 patients in the control group versus only 2 in the endoscopic treatment group (25.8% vs. 6.2%, p < 0.05). Hospital stay was longer for the control group (5.5 +/- 0.2, median 6.0, range 2.0-8.0 days vs. 3.4 +/- 0.2, median 3.0, range 2.0-6.0 days; p < 0.001). There was a trend toward a higher transfusion requirement after endoscopy in the control group versus the patients treated by injection (0.9 +/- 0.2, median 0.0, range 0.0-4.0 units vs. 0.2 +/- 0.1, median 0.0, range 0.0-2.0 units; p = 0.09). No complications or adverse events caused by endoscopic injection were noted. Two patients in the control group died of causes unrelated to bleeding.
CONCLUSIONS: Endoscopic injection therapy is a useful option in the management of patients with Mallory-Weiss syndrome at high risk for recurrent bleeding.

PMID 11726841  Gastrointest Endosc. 2001 Dec;54(6):679-81.
著者: S Lecleire, M Antonietti, I Iwanicki-Caron, A Duclos, S Ramirez, E Ben-Soussan, S Hervé, P Ducrotté
雑誌名: Aliment Pharmacol Ther. 2009 Aug 15;30(4):399-405. doi: 10.1111/j.1365-2036.2009.04051.x. Epub 2009 May 26.
Abstract/Text 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.

PMID 19485979  Aliment Pharmacol Ther. 2009 Aug 15;30(4):399-405. doi:・・・
著者: Chang-Hwan Park, Sang-Woon Min, Young-Hae Sohn, Wan-Sik Lee, Young-Eun Joo, Hyun-Soo Kim, Sung-Kyu Choi, Jong-Sun Rew, Sei-Jong Kim
雑誌名: Gastrointest Endosc. 2004 Jul;60(1):22-7.
Abstract/Text BACKGROUND: Effective hemostatic treatment is mandatory for patients with actively bleeding Mallory-Weiss syndrome. This study evaluated the respective efficacy and the safety of endoscopic band ligation and endoscopic epinephrine injection in Mallory-Weiss syndrome.
METHODS: Thirty-four consecutive patients with actively bleeding Mallory-Weiss syndrome were prospectively enrolled and were randomly assigned to undergo endoscopic band ligation or endoscopic injections of a 1:10,000 solution of epinephrine. Demographic characteristics, endoscopic variables, and outcome parameters, including rates of hemostasis and recurrent bleeding, were analyzed.
RESULTS: The number of elastic bands applied was one or two; the mean volume of epinephrine injected was 18.0 mL: 95% CI[16.8, 19.2]. There was no significant difference between the groups with respect to age, gender, alcohol ingestion, presenting symptoms, Hb level, shock, comorbid diseases, coagulopathy, tear location, blood transfusion, or duration of hospitalization. Primary hemostasis was achieved in all 17 patients in the band ligation group and in 16 of 17 patients (94.1%) in the epinephrine injection group. There was no recurrence of bleeding or major complication in either group.
CONCLUSIONS: In this small study, no difference was detected in the efficacy or the safety of band ligation vs. epinephrine injection for the treatment of actively bleeding Mallory-Weiss syndrome.

PMID 15229420  Gastrointest Endosc. 2004 Jul;60(1):22-7.
著者: Young-Seok Cho, Hiun-Suk Chae, Hyung-Keun Kim, Jin-Soo Kim, Byung-Wook Kim, Sung-Soo Kim, Sok-Won Han, Kyu-Yong Choi
雑誌名: World J Gastroenterol. 2008 Apr 7;14(13):2080-4.
Abstract/Text AIM: To compare the hemostatic efficacy and safety of two mechanical endoscopic methods: endoscopic band ligation (EBL) and endoscopic hemoclip placement (EHP) in patients with actively bleeding Mallory-Weiss syndrome (MWS).
METHODS: A prospective randomized study to compare the efficacy and safety of EHP with EBL was performed from January 2002 to August 2005. Forty-one patients with active bleeding from MWS were treated with EHP (n = 21) or EBL (n = 20).
RESULTS: There were no significant differences between groups with respect to clinical and endoscopic characteristics. The mean number of hemoclips applied was 3.2 +/- 1.5 and the mean number of bands applied was 1.2 +/- 0.4. Primary hemostasis was achieved in all patients. Recurrent bleeding was observed in one patient from the EHP group and two from the EBL group. Patients with recurrent bleeding were treated by the same modality as at randomization and secondary hemostasis was achieved in all. There were no significant differences between the two groups in total transfusion amount or duration of hospital stay. No complications or bleeding-related death resulted.
CONCLUSION: EHP and EBL are equally effective and safe for the management of active bleeding in patients with Mallory-Weiss syndrome, even in those with shock or comorbid diseases.

PMID 18395910  World J Gastroenterol. 2008 Apr 7;14(13):2080-4.
著者: Shih-Pei Huang, Hsiu-Po Wang, Yi-Chia Lee, Chun-Che Lin, Chang-Shiu Yang, Ming-Shiang Wu, Jaw-Town Lin
雑誌名: Gastrointest Endosc. 2002 Jun;55(7):842-6.
Abstract/Text BACKGROUND: Mallory-Weiss syndrome with active bleeding requires effective hemostasis. This is an investigation of the respective efficacy and safety of endoscopic hemoclip placement and endoscopic epinephrine injection in Mallory-Weiss syndrome.
METHODS: Thirty-five patients with Mallory-Weiss syndrome with spurting vessels or oozing in a university hospital were enrolled prospectively and randomly assigned to endoscopic hemoclip placement (18 patients) or endoscopic epinephrine injection (17 patients) performed by 4 endoscopists with similar clinical experiences. Demographic characteristics, endoscopic variables, and outcome parameters as well as rates of hemostasis and recurrent bleeding were analyzed.
RESULTS: The mean (SD) number of hemoclips applied was 2.5 (1.2) and the mean volume of injection was 7.9 (4.3) mL. Primary hemostasis was achieved in all 35 patients. In each group there was 1 case of recurrent bleeding. Secondary hemostasis was achieved by repeating the same procedures as at randomization in both cases. There were no significant differences in age, gender, prior ingestion of alcohol, presenting symptoms, hemoglobin level, shock, comorbid diseases, bleeding stigmata, tear location, blood transfusion, or hospitalization between the groups. There were no procedure-related complications in either group; surgery was not required in any patient. For both groups, there were no second episodes of recurrent bleeding, procedure-related complication, or need of operation.
CONCLUSION: Endoscopic hemoclip placement and endoscopic epinephrine injection are equally effective and safe for the management of active bleeding in Mallory-Weiss syndrome, even in patients with shock or comorbid diseases.

PMID 12024138  Gastrointest Endosc. 2002 Jun;55(7):842-6.
著者: Y Yamaguchi, T Yamato, N Katsumi, K Morozumi, T Abe, H Ishida, S Takahashi
雑誌名: Gastrointest Endosc. 2001 Apr;53(4):427-30. doi: 10.1067/mge.2001.111774.
Abstract/Text BACKGROUND: Endoscopic hemoclipping is known to be highly effective as hemostatic treatment for upper gastrointestinal bleeding. However, the efficacy and safety of hemoclipping for Mallory-Weiss syndrome (MWS) have not been reported. Thus, the aim of the present study was to assess prospectively the usefulness of endoscopic hemoclipping for MWS bleeding.
METHODS: This study was conducted from January 1994 to August 1999. Hemoclipping was performed when active bleeding (spurting, streaming or oozing), visible vessels or fresh adhesive clots were found on endoscopic examination. Patients who did not have any of these findings were conservatively treated. Follow-up endoscopy was performed within 24 hours, after 5 days and between 1 and 2 months after the procedure.
RESULTS: MWS was diagnosed in a total of 58 patients during the study. Hemoclipping was performed in 26 patients and was technically successful in all cases. The average number of hemoclips used was 2.8 +/- 1.6 (range 1 to 8). The number of hemoclips required for hemostasis depended on the nature of the bleeding. No complications, recurrent bleeding, or deaths resulted. Follow-up endoscopy showed no evidence of hemoclip-induced tissue injury and no impairment of Mallory-Weiss tears.
CONCLUSION: Endoscopic hemoclipping provided an effective and safe modality for obtaining hemostasis when bleeding is due to MWS.

PMID 11275881  Gastrointest Endosc. 2001 Apr;53(4):427-30. doi: 10.106・・・
著者: Ryo Shimoda, Ryuichi Iwakiri, Hiroyuki Sakata, Shinichi Ogata, Hibiki Ootani, Yasuhisa Sakata, Takehiro Fujise, Kanako Yamaguchi, Kotaro Mannen, Seichiro Arima, Ryosuke Shiraishi, Takahiro Noda, Akihiro Ono, Seiji Tsunada, Kazuma Fujimoto
雑誌名: Dig Endosc. 2009 Jan;21(1):20-3. doi: 10.1111/j.1443-1661.2008.00825.x.
Abstract/Text AIM: Applied endoscopic techniques including mucosal resection, sclerotherapy and endoscopic retrograde cholangiopancreatography (ERCP) have been advanced and iatrogenic complications including Mallory-Weiss tear (MWT) occasionally occur in daily endoscopic procedures. The present study aimed to examine the advantages of clipping for MWT complications that occur during endoscopic examination.
METHODS: Over 10 years, we experienced 47 patients with bleeding caused by MWT. Metallic hemoclips were applied for 38 patients for hemostasis. These patients were categorized into two groups: 18 patients in group A whose bleeding tear occurred during endoscopic examination in an iatrogenic condition, and 20 patients in group B visited the emergency unit due to other etiology of MWT.
RESULTS: The background characteristics, including length of tears, were not different between the two groups. Initial hemostasis was 100% in groups A and B. Rebleeding was 0/18 (0%) in group A and 1/20 (5 %) in group B. Number of patients who received blood transfusion was significantly higher in group B (group A: 0/18, group B: 4/20). Hemoglobin level before hemostasis was 12.5 g/dL in group A which was not different to that in group B, 10.9 g/dL.
CONCLUSION: Application of hemoclips was effective for bleeding MWT during endoscopic procedures, which warranted prophylactic application of hemoclips on MWT during endoscopic examination.

PMID 19691796  Dig Endosc. 2009 Jan;21(1):20-3. doi: 10.1111/j.1443-16・・・
著者: A E Bharucha, C J Gostout, R K Balm
雑誌名: Am J Gastroenterol. 1997 May;92(5):805-8.
Abstract/Text OBJECTIVES: Although patients with bleeding Mallory-Weiss tears are generally hospitalized, we wished to develop guidelines facilitating the selection, by clinical and endoscopic criteria, of patients who do not need hospitalization. Our specific aims were to determine whether presenting manifestations of bleeding differed in hemodynamically unstable patients, whether active bleeding or stigmata of bleeding at endoscopy were prognosticators for significant rebleeding, and the outcomes in endoscopically managed patients.
METHODS: The endoscopic and clinical features of all patients with acute GI bleeding from a Mallory-Weiss tear were obtained from our GI Bleeding Team database over a consecutive 4-yr period and analyzed for prognostic indicators.
RESULTS: 1) Presenting manifestations, e.g., hematochezia, were significantly different in hypotensive patients. 2) Active bleeding but not stigmata was associated with higher transfusion requirements. 3) Rebleeding was unusual, occurring within 24 h, more often in patients with a bleeding/coagulation diathesis. The median hospital stay was 4 days (range 1-24). Fifty-seven percent of patients received transfusion (median 4 units, range 1-26 units); requirements were higher in patients with coagulopathies.
CONCLUSIONS: Patients without risk factors for rebleeding (portal hypertension, coagulopathy), clinical features indicating severe bleeding (hematochezia, hemodynamic instability), or active bleeding at endoscopy can be managed with a brief period of observation. Patients with endoscopically active bleeding may benefit from endoscopic therapy.

PMID 9149189  Am J Gastroenterol. 1997 May;92(5):805-8.

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