Esophageal Rupture Syndrome

　　First, etiology

　　Esophageal mucosal tear syndrome often occurs after severe vomiting, and alcoholism is a common cause. Many other diseases, such as peptic ulcer disease, intestinal obstruction caused by gastrointestinal malignant tumors, uremia, atrophic gastritis, severe vomiting during pregnancy, delivery, severe exercise, migraine, strenuous defecation, and so on, are also related to Mallory-Weiss syndrome. It is especially common to have a hiatal hernia. Sato et al. (1989) reported that the incidence of hiatal hernia in the cases was as high as 91%, and it is believed that hiatal hernia is one of the risk factors for Mallory-Weiss syndrome. Some people also found that these patients often have coagulation and anticoagulation dysfunction.

　　Second, pathogenesis

　　1. Pathogenesis:The mechanism of esophageal mucosal tearing is not fully understood. It is generally believed that it is caused by the entry of gastric contents into the spasmodic esophagus during vomiting, plus diaphragmatic contraction, which causes the intraluminal pressure of the distal esophagus to increase sharply, leading to mucosal tearing at the cardia. Some people have used cadavers for research, and it can cause tearing at the esophagus-gastric junction when the intragastric pressure is maintained at 150mmHg and the esophagus is blocked. It has been found that the intragastric pressure of normal healthy adults can reach 200mmHg when they are nausea. Many people believe that the mechanism of esophageal mucosal tear syndrome is similar to that of spontaneous esophageal rupture, which can be full-thickness esophageal rupture and cause esophageal perforation, or it can be only intramural hematoma or only mucosal tearing.

　　2. Pathology and staging:Most of the tearing sites are at the end of the esophagus or across the esophagus-gastric junction, mostly linear single tears, but there are also tears in two or even multiple places. The tearing mostly occurs in the grooves between the mucosal folds. According to a report of 224 cases of Mallory-Weiss syndrome, 83% of the tears are located on the small curvature of the esophagus-gastric junction. In the early stage, active bleeding can be seen, or there may be blood clots or fibrin clots covering it, and in the late stage:

　　(1) Bleeding stage: Bleeding is ongoing, within 24 hours after the onset of the disease.

　　(2) Open stage: The wound is split open, the edges are raised, 48h to 7 days.

　　(3) Linear stage: The fissure is linear, close to closure, with white fur attached, lasting for 1 to 2 weeks.

　　(4) Scar stage: White fur disappears, scar formation, lasting for 2 to 3 weeks.

　　In addition to general symptoms, it can also cause other diseases. The most common complication of this disease is bleeding (blood loss). If there is vomiting of blood or bloody stools, immediate medical attention should be sought. Therefore, once found, active treatment is needed, and preventive measures should also be taken in daily life.

　　1. Vomiting or nausea:According to a large number of literature reports, almost all Mallory-Weiss syndrome patients have vomiting or nausea at the time of onset, and some patients may not have severe vomiting, but they can still develop Mallory-Weiss syndrome. It can be seen that the severity of vomiting is not necessarily causally or parallelly related to the occurrence of the syndrome. However, about 9% of patients are caused by other causes of nausea and vomiting, such as patients who undergo surgery for other diseases and experience hiccups during anesthesia, which can also lead to Mallory-Weiss syndrome.

　　2. Hematemesis or melena:Hematemesis or melena is the second important clinical symptom of Mallory-Weiss syndrome patients. The interval between vomiting and hematemesis varies from patient to patient. Some patients may have hematemesis immediately after vomiting, while others may only have hematemesis or melena days after severe vomiting symptoms.

　　One important clue for diagnosing Mallory-Weiss syndrome is that patients often have a history of vomiting one or more times of normal gastric contents before hematemesis or massive melena. However, some patients may present with massive hematemesis from the onset, and it is painless, presenting as a large amount of bright red blood. If not treated promptly, patients often die due to hemorrhagic shock.

　　3. Upper abdominal pain:Mallory-Weiss syndrome patients sometimes have upper abdominal pain, but in most cases, there are no abdominal pain symptoms. Upper abdominal pain can appear quickly after hematemesis or even before hematemesis. Some patients may feel a tearing-like pain in the upper abdomen before nausea and vomiting, which is persistent; some patients may feel that the location of abdominal pain is deeper. According to reports by Freeark et al. (1964), such patients were found to have extensive submucosal bleeding in the cardia during laparotomy. In cases where the esophageal cardia mucosa is completely torn, upper abdominal pain is an outstanding clinical symptom. Because of the severe abdominal pain, the bleeding symptoms of the upper gastrointestinal tract are easily overlooked, which is one of the causes of misdiagnosis.

　　4. Shock:Massive hematemesis can lead to hemorrhagic shock, threatening the patient's life safety. Most Mallory-Weiss syndrome patients have mild to moderate bleeding, while only a small number of patients have massive bleeding. Slow and persistent hematemesis or intermittent hematemesis can also cause hemorrhagic shock in patients. The upper gastrointestinal bleeding symptoms in most Mallory-Weiss syndrome patients can stop spontaneously without the need for surgical treatment. Less than 10% of active upper gastrointestinal arterial bleeding or massive venous bleeding are caused by long-term portal hypertension and esophageal variceal rupture. Attention should be paid to this condition when diagnosing Mallory-Weiss syndrome, and careful differential diagnosis should be performed.

　　Among the 23 patients reported by Miller and Hirschowitz (1970), one patient with hematemesis failed to respond to conservative medical treatment and died due to sudden cardiac arrest, while all six patients treated with surgical intervention were cured. Therefore, Mallory-Weiss syndrome patients who require surgical treatment cannot delay the timing of surgery.

　　Avoid excessive alcohol consumption, and try to alleviate vomiting and coughing as soon as possible. The patient's diet should be light and easy to digest, with an emphasis on vegetables and fruits, a reasonable dietary balance, and ensuring adequate nutrition. In addition, patients should also pay attention to avoiding spicy, greasy, and cold foods.

　　1. Gastroscopy:Mallory-Weiss lesions are mostly located at the esophagus-gastric junction, therefore, gastroscopy has a better diagnostic value than esophagoscopy.

　　In the 23 cases of Mallory-Weiss syndrome reported by Millet and Hirschowitz (1970), 19 cases were diagnosed by gastroscopy, among which 12 cases showed longitudinal tearing injuries at the gastroesophageal junction mucosa under gastroscopy, accounting for 55%; 7 cases (30%) did not show obvious damage to the esophageal and gastric mucosa under gastroscopy, but bleeding still came from the esophagus-gastric junction; 3 cases were unsatisfactory during gastroscopy due to excessive blood in the stomach, and a diagnosis could not be made; 1 case did not undergo gastroscopy, and during surgical exploration, esophageal mucosal tearing and bleeding were found at the lower esophagus. Thus, in the 23 cases reported by Miller and Hirschowitz, 85% (19/23) were diagnosed after gastroscopy, indicating that gastroscopy has diagnostic value that cannot be replaced by other examinations. If there are no contraindications, gastroscopy should be performed first.

　　2. Upper gastrointestinal barium meal radiography:Barium meal radiography of the upper gastrointestinal tract cannot show the esophageal cardia mucosal tearing lesions in Mallory-Weiss syndrome; its main role is to exclude other causes of upper gastrointestinal bleeding. However, some authors have reported that when the esophageal cardia mucosal tearing is severe, upper gastrointestinal air-barium contrast radiography can show the lesion, characterized by the sign of barium filling at the site of mucosal tearing.

　　3. Selective celiac artery angiography:According to literature reports, some authors have adopted selective celiac artery angiography to display the specific location of upper gastrointestinal bleeding and make a diagnosis of Mallory-Weiss syndrome.

　　Extensive clinical practice has shown that many patients with unknown causes of upper gastrointestinal bleeding, who undergo surgical exploration due to the ineffectiveness of conservative medical treatment, are later diagnosed with Mallory-Weiss syndrome. According to some authors' retrospective analysis, some patients have typical clinical features of Mallory-Weiss syndrome before surgery, which can be diagnosed as Mallory-Weiss syndrome. Moreover, the vast majority of these patients underwent surgical exploration, and the specific bleeding site was clearly identified after incising the anterior wall of the stomach during surgery.

　　For patients with hematemesis and melena, pay attention to the following diet:

　　Firstly,Dietary medicine

　　1. Chinese flowering cabbage, also known as chrysanthemum flower, has the effects of clearing the liver, cooling blood, and hemostasis. For upper gastrointestinal bleeding due to stomach heat or liver fire, eating this product can be used as an auxiliary treatment.

　　2. Water spinach, also known as hollow vegetable or heartless vegetable. Eating it (raw or cooked) can clear the heat in the gastrointestinal tract. The scope of application is the same as above.

　　3. Fresh lotus root can cool blood and remove blood stasis. For upper gastrointestinal bleeding caused by stomach heat or liver fire, drinking fresh lotus root juice can be used as an auxiliary treatment.

　　4. Fungus, also known as Tremella fuciformis, has the effect of cooling blood and hemostasis. This product can be burned into charcoal, ground into powder, and taken as a decoction or used in medicine decoction to have a hemostatic effect. The indications are the same as above.

　　5. Nasturtium, also known as thistle, is a wild vegetable commonly eaten in the countryside. This product has the effects of clearing heat, cooling blood, and hemostasis. It can be cooked into a decoction or eaten raw. The indications are the same as above.

　　6. shepherd's purse has the effects of cooling the liver and hemostasis. Both raw and cooked forms can be eaten. It can be used as a dietary therapy for upper gastrointestinal bleeding due to liver fire.

　　7. Sassafras flowers have the effects of clearing heat, cooling blood, and hemostasis. This product can be decocted into a decoction and taken as tea, which can be used as an auxiliary treatment for hematochezia.

　　Secondly,Medicinal Diet

　　1. White Root and Nasturtium Drink Take 30-60 grams of fresh white root and fresh Nasturtium officinale, clean, squeeze the juice. Take twice a day. It can be used as an auxiliary treatment for upper gastrointestinal bleeding due to stomach heat or liver fire.

　　2. Chinese Flowering Cabbage Drink Take 60 grams of Chinese flowering cabbage, 60 grams of fresh lotus root (sliced), and 30 grams of white root, decoct into a decoction and take it. The indications are the same as above.

　　3. Panax notoginseng Lotus Root and Egg Soup The recipe is the same as the part on chronic gastritis and peptic ulcer. The indications are the same as above.

　　4. Three Juices with Panax notoginseng Fresh white root, fresh lotus root, and fresh small Nasturtium officinale each 30 grams, clean and squeeze the juice, mix with 100 milliliters of milk, add 3 grams of Panax notoginseng powder, and drink. The indications are the same as above.

　　5. Modified Ziziphus jujuba Seed and Oryza sativa Porridge Take 30 grams of white root, decoct in water, filter the juice, add 60 grams of fresh lotus root slices, 100 grams of glutinous rice, and cook into porridge. Add 6 grams of finely powdered Ziziphus jujuba seed at the last stage of cooking. Take twice a day. This porridge can be used as an auxiliary treatment for upper gastrointestinal bleeding with liver fire.

　　6. Take 30 grams of Alisma orientale, lotus seeds (peeled and dehulled), and 30 grams of山药, 100 grams of glutinous rice, add an appropriate amount of water, and cook into porridge. Take 3 grams of Alisma orientale powder twice a day. This formula is suitable for auxiliary treatment for upper gastrointestinal bleeding due to Qi deficiency.

　　7. Take 1 tender hen, kill and clean it, remove feathers, open the abdomen, and clean the internal organs; put 15 grams of Astragalus membranaceus, 15 grams of Codonopsis pilosula, 9 grams of Atractylodes macrocephala, 6 grams of Panax notoginseng, and 6 grams of dried tangerine peel in a gauze bag, and place it in the abdominal cavity of the chicken; put the chicken in a pot, add an appropriate amount of water, and add an appropriate amount of scallions, ginger, and salt, simmer over low heat until the chicken is tender, remove the medicine bag, and eat the meat and drink the soup. The indications are the same as above.

　　Third,Types of diet and indications

　　1. Fasting:Patients with esophageal and gastric variceal bleeding, severe upper gastrointestinal bleeding accompanied by nausea and vomiting should be fasting for 1 to 3 days, but sufficient fluid and electrolytes should be supplemented for the patient, and fresh blood transfusion may be necessary if necessary.

　　2. Liquid Diet No. 1:For patients with minor bleeding without vomiting and no obvious active bleeding, liquid diet No. 1 is adopted, but sufficient fluid and electrolytes should be supplemented for the patient. Anemia patients should be supplemented with fresh blood. This period usually requires 2 to 3 days. During this period, the diet can reduce the contraction of the stomach and lower the acidity of the gastric juice. The main content is milk and lotus root starch, 100 to 200ml per meal, six meals a day, with a total calorie intake of 800 calories.

　　3. Liquid Diet No. 2:Appropriate for patients after hemorrhage cessation, which usually requires about 5 to 7 days. During this period, according to the situation, the patient can be supplemented with a small amount of fluid and electrolytes, with a quantity of 200 to 300ml, six meals a day, adding biscuits, breadsticks, cakes, and can also eat soft noodles, noodles, etc., with a total calorie intake of 2080 calories per day.

　　4. Liquid Diet No. 3:Appropriate for patients with stable conditions after hemorrhage cessation, which usually requires about 10 to 15 days. During this period, the diet should be free of stimulation, low in residue, and semi-liquid. The content includes milk, thin congee, bread, noodles, stewed fish, with five meals a day, and a total calorie intake of 2142 calories.

　　5. Semi-liquid diet:Appropriate for patients in the recovery stage after hemorrhage cessation, which lasts about 15 to 20 days. The diet should mainly consist of soft and easily digestible semi-liquid foods, such as congee, steamed buns, bread, minced vegetables, meatballs, fish, etc., with four meals a day.

　　6. Normal diet:For patients in the convalescent period of peptic hemorrhage, the diet should consist of soft, easily digestible, non-irritating, and nutritious food. The patient should have three meals a day, and should not eat too much.

　　First, treatment

　　In general, Mallory-Weiss syndrome is first treated with medical treatment, actively correcting the deficiency or coagulation disorders of coagulation factors.

　　1. Non-surgical treatment:The main medical treatment methods for Mallory-Weiss syndrome include lavage of the stomach with ice saline solution containing norepinephrine, blood transfusion, intravenous infusion of hemostatics and histamine H2-receptor blockers (such as cimetidine or ranitidine), intravenous fluid administration, and gastrointestinal decompression, among other measures.

　　(1) Lavage of the stomach with ice saline solution of norepinephrine: Norepinephrine has a strong contractile effect on smooth muscle, especially on vascular smooth muscle. It is usually administered by adding 8mg of norepinephrine to 250ml of ice saline solution and injecting it into the stomach through a gastric tube. The solution is retained in the stomach for 20 to 30 minutes before being aspirated, and the lavage is repeated, which has a good hemostatic effect.

　　Individual cases are effective with the treatment of antidiuretic hormone (vasopressin), and the bleeding in the upper gastrointestinal tract can be controlled.

　　(2) Blood transfusion: Blood volume supplementation is an important measure for the treatment of Mallory-Weiss syndrome, which can prevent hemorrhagic shock. According to the experience of Freeark et al., the amount of blood transfusion ranges from 2000ml to 9500ml, with an average of 5770ml. Preoperative preparation for massive blood transfusion is required for cases requiring surgical treatment.

　　(3) Mesenteric artery embolization: Some authors have reported the use of selective mesenteric artery embolization (embolizing the left gastric artery and its branches) to treat Mallory-Weiss syndrome, considering the hemostatic effect satisfactory, but the laceration of the esophageal and cardia mucosa is severe, and the lesions are multiple, making this therapy difficult to be effective.

　　(4) Endoscopic hemostasis: Some authors have reported that the local area of Mallory-Weiss lesions can be treated by applying a cotton swab soaked in norepinephrine solution, or by electrocoagulation hemostasis of the active bleeding points at the tear site through the endoscope, which can achieve the purpose of cure in some cases.

　　(5) Compression hemostasis with a three-way tube: In recent years, most authors do not advocate the use of a three-way tube for compression hemostasis in Mallory-Weiss syndrome patients because the pressure inside the three-way tube is not sufficient to compress and stop the upper gastrointestinal artery bleeding. Exploratory surgery or post-mortem examination has confirmed that the cuff inside the three-way tube not only failed to achieve the purpose of compression hemostasis but also aggravated the laceration of the esophageal and cardia mucosa, resulting in increased bleeding.

　　2. Surgical treatment

　　(1) Indications for surgery:

　　① Upper gastrointestinal bleeding that cannot be stopped after regular medical treatment or has transformed into massive bleeding;

　　② Large amounts of upper gastrointestinal bleeding stop after conservative medical treatment but recur, and the amount of bleeding is large, and it is estimated that it is difficult to control with further medical treatment;

　　③ Patients with massive hematemesis and critical condition.

　　Mallory-Weiss syndrome is often diagnosed clinically as 'unexplained massive upper gastrointestinal bleeding' and undergoes exploratory surgery. In fact, Mallory-Weiss syndrome is just one of the causes of upper gastrointestinal bleeding.

　　(2) Preoperative preparation: Evaluate the amount of bleeding; perform gastroscopy to determine the specific bleeding site; exclude bleeding caused by esophageal varices rupture, and perform surgical exploration under general anesthesia.

　　(3) Surgical procedure:

　　The patient is placed in a supine position and a median or para-medial incision is made in the upper abdomen. The abdomen is opened layer by layer. After the abdomen is opened, the stomach and duodenum are palpated first to exclude upper gastrointestinal bleeding caused by other reasons. The majority of Mallory-Weiss syndrome patients are normal during endoscopy and palpation, and it is difficult to find the bleeding site and lesion.

　　After the endoscopy and palpation, the stomach and lower esophagus should not be freed immediately. A diagonal incision is made in the middle 1/3 of the anterior wall between the greater curvature and lesser curvature of the stomach, exposing the stomach cavity. The blood and blood clots in the stomach are aspirated with a suction device, and a small gauze is temporarily used to block the pylorus of the stomach to carefully observe the source of bleeding in the upper gastrointestinal tract.

　　③If bleeding is seen above the pylorus but no hemorrhagic lesions are visible, extend the incision at both ends of the anterior gastric wall by 4 cm, so that the upper and lower ends of the incision are each about 4 cm away from the pylorus and the esophagus-gastric junction. Flip the gastric wall incision to the left and right sides and outward, which can clearly display the entire gastric cavity mucosa for examination. However, the mucosa at the esophagus-gastric junction is still not visible. In this situation, the surgeon can use a curved hemostat to clamp the front end of the gastric tube inside the gastric cavity and ask the anesthesiologist to fix the gastric tube at the patient's external nostril. The surgeon can then pull downwards and forwards with appropriate force on the front end of the gastric tube clamped by the hemostat, which can bring the mucosa of the cardia along with the grayish mucosa of the lower esophagus into the surgical field, thus exposing the mucosal folds or concave areas of the esophagus-gastric junction. This can further help to discover the mucosal tears and bleeding at the esophagus-cardiac orifice. If a Deaver retractor or S-shaped retractor is inserted into the gastric cavity and slightly pulled, it is more helpful to expose the surgical field.

　　④Tie off (suture) each visible mucosal tear at the esophageal-cardiac orifice and submucosal active arteriovenous hemorrhage points one by one to stop bleeding or coagulate with electricity. After that, suture each mucosal tear along with the submucosa and muscular layer continuously inside the gastric cavity. The best suture thread to use is 5-0 absorbable suture. First, suture from the lower end of the mucosal tear upwards, tie the knot after reaching the upper end of the mucosal tear; then, you can reverse the needle from the upper end of the mucosal tear and suture downwards in the same manner, making the two suture lines cross each other. Tie the knot after reaching the lower end of the tear. This double-cross continuous suture technique for repairing esophageal-cardiac orifice mucosal tears has a more reliable hemostatic effect, but it is important to include more of the deep muscular layer tissue during suture to prevent the formation of hematoma or continued bleeding at the muscular layer tear site beneath the mucosa. After suture, check the suture site repeatedly and carefully for bleeding, and stop any bleeding points.

　　⑤When encountering cases of esophageal-cardiac orifice full-thickness penetrating tears, first close the tear from inside the gastric cavity with absorbable suture in a continuous full-thickness inversion suture technique. Then, use a small round needle and fine silk thread to suture the serosal or muscular layer (outer layer) of the tear in an interrupted manner. Subsequently, use a pedicled diaphragmatic flap or pericardial patch to suture and cover the tear, making the repair of the tear more safe and reliable and preventing postoperative tear fistula.

　　⑥Suture the incision of the anterior gastric wall with interrupted or continuous inversion suture technique. For patients with esophageal hiatus hernia or gastroesophageal reflux symptoms before surgery, concurrent anti-reflux surgery should be performed, such as fundoplication. Some authors advocate installing a gastric gastrostomy tube by making an additional incision on the anterior gastric wall after closing the incision of the anterior gastric wall for postoperative gastrointestinal decompression. The advantage is that the nasogastric tube can be removed after the operation, avoiding the continued compression of the mucosal tear at the esophageal cardiac orifice, which may cause secondary hemorrhage. Some authors, however, advocate the continued use of a nasogastric tube for gastrointestinal decompression after surgery. Both opinions have their merits. Currently, in clinical practice, after surgical treatment for Mallory-Weiss syndrome, nasal gastric tubes are generally used for gastrointestinal decompression.

　　⑦ Suture the abdominal incision in layers and close the abdomen.

　　3. Postoperative management:The postoperative management of Mallory-Weiss syndrome patients includes:

　　(1) Fast for the first week after surgery, continue gastrointestinal decompression, closely observe the nature and quantity of gastrointestinal drainage fluid, and be vigilant about the recurrence of upper gastrointestinal bleeding postoperatively.

　　(2) Use parenteral hyperalimentation to maintain the patient's nutrition, pay attention to correct water and electrolyte imbalances and acid-base disturbances; use highly effective broad-spectrum antibiotics to prevent abdominal and incisional infections.

　　(3) Remove the gastric tube (gastric fistula tube should be removed on the 10th day after surgery) on the 5th or 7th day after the operation, depending on the condition.

　　(4) Stop gastrointestinal decompression and gradually resume oral intake.

　　(5) Timely management of postoperative complications.

　　4. Surgical effects:In 1964, Freeark et al. reported that 12 cases of Mallory-Weiss syndrome were cured in 7 cases after surgical suture and hemostasis, 3 died of postoperative pneumonia complicated with acute liver dysfunction or myocardial infarction, and 2 died of postoperative gastric wall fistula.

　　Some authors have reported that in 13 cases of upper gastrointestinal bleeding of unknown etiology, no bleeding cause was found during laparotomy, but bleeding stopped and the patient recovered after undergoing a 'blind' subtotal gastrectomy. Other authors have reported that patients with unexplained upper gastrointestinal bleeding who underwent a 'blind' subtotal gastrectomy died, and it was later found that the cause of bleeding was Mallory-Weiss syndrome. Clinical experience has repeatedly shown that if Mallory-Weiss lesions are missed during surgical exploration, patients often die of upper gastrointestinal bleeding postoperatively.

　　According to recent large case reports, the surgical efficacy of Mallory-Weiss syndrome is satisfactory, with rare cases of postoperative bleeding recurrence and a mortality rate of less than 5%.

　　The choice of treatment method is mainly based on the severity of bleeding, the patient's overall condition, and whether there are other concurrent diseases. In the past, the surgical rate for this syndrome was as high as 46%, but recent reported data show that the surgical rate has明显下降明显下降, and in the absence of severe massive bleeding, non-surgical treatment can usually be adopted, but it is necessary to promptly replenish blood volume, prevent aspiration of respiratory tract, fasting, and the use of drugs to inhibit gastric acid secretion (such as H2 receptor antagonists), closely monitor hemodynamic changes, and try to correct coagulation dysfunction. Other non-surgical treatment measures are the same as those for ulcer bleeding, and can include lavage of the stomach with ice water, oral administration of cimetidine, intravenous infusion of pituitary posterior lobe extract and vitamin K, and also balloon compression for hemostasis. Recently, a transparent esophageal balloon made of polyurethane film has been used, which is inserted into the stomach through an endoscope and observed under direct vision for hemostasis. This method has the following advantages over the previous Sengstaken-Blakemore balloon compression hemostasis method:

　　(1) The success rate of hemostasis is high, almost reaching 100%.

　　(2) This method can observe whether bleeding has stopped under direct vision.

　　(3) It can be used for a relatively long time, and hemostasis may also be achieved in patients with coagulation dysfunction.

　　(4) This balloon has good quality and exerts uniform pressure on the surrounding area.

　　(5) Select a lower effective hemostatic pressure, maintain it for 12 to 24 hours, which can usually achieve hemostasis and is not easy to cause esophageal injury even if it is left in place for a long time.

　　Nusbaum introduced selective infusion of vasopressin through the left gastric artery to control bleeding, which achieved good hemostatic effects and could be performed immediately after angiography to identify the bleeding site. Endoscopic treatment also has many successful experiences, including electrocoagulation hemostasis, ND:YAG laser treatment, and local sclerosing agent injection, etc. Bataller et al. reported 50 cases of Mallory-Wiess syndrome, 13 of which had active bleeding, all of which were treated successfully with sclerosing agent injection (1/10000 adrenaline 1% polidocanol) under endoscopy.

　　5. Most cases of esophageal mucosal tear syndrome can be cured by non-surgical therapy, but surgery is still required in the following situations:

　　(1) Life-threatening massive hemorrhage, Hlastings (1981) reported that less than 500ml of blood transfusion does not require surgical treatment, and more than 1500ml of blood transfusion requires consideration of surgery; 77.8% of those with more than 2000ml of blood transfusion require surgery.

　　(2) Recurrent bleeding despite active treatment.

　　(3) Suspected esophageal rupture.

　　Surgery is generally easy. After high gastric incision, carefully examine the esophagus, gastric fundus, and esophagus-gastric junction. If esophageal mucosal tears are found, continuous suture can achieve hemostasis. However, it should be noted that small and unobvious tears may be missed, and there have been reports of postoperative death due to this. Some authors perform vagotomy and pyloroplasty at the same time to try to control possible pathogenic factors, but it is generally not necessary, and a few cases may require subtotal gastrectomy.

　　II. Prognosis

　　Recently reported that 8.5% to 30% of patients with esophageal mucosal tear syndrome require surgical treatment, with a mortality rate of 0 to 10%. The mortality rate of non-surgical treatment is 0 to 14%. Recurrent bleeding is rare, and the prognosis is generally good, especially for non-drinkers. The high-risk factor for recurrent bleeding is the presence of portal hypertension.