Mallory-Weiss Tear: Causes, Symptoms, Treatment

Severe and prolonged vomiting can result in tears in the lining of the esophagus. The esophagus is the tube that connects your throat to your stomach.

Mallory-Weiss syndrome (MWS) is a condition marked by a tear in the mucous membrane, or inner lining, where the esophagus meets the stomach.

Most tears heal within 72 hours without treatment, but Mallory-Weiss tears can cause significant bleeding. Depending on the severity of the tear, surgery may be necessary to repair the damage.

The most common cause of MWS is severe or prolonged vomiting. While this type of vomiting can occur with stomach illness, it also frequently occurs due to chronic alcohol use or bulimia.

Other conditions can result in a tear of the esophagus as well. These include:

• trauma to the chest or abdomen
• severe or prolonged hiccups
• intense coughing
• heavy lifting or straining
• gastritis, which is an inflammation of the lining of the stomach
• hiatal hernia, which occurs when part of your stomach pushes through part of your diaphragm
• convulsions

Receiving cardiopulmonary resuscitation (CPR) can also lead to a tear of the esophagus.

MWS is more common in males than in females. It occurs more often in people with alcoholism. According to the National Organization for Rare Disorders, people between the ages of 40 and 60 are more likely to develop this condition. However, there are cases of Mallory-Weiss tears in children and young adults.

There are a few predisposing factors that can put you at risk of Mallory-Weiss tears. These can include:

• heavy alcohol consumption
• bulimia nervosa diagnosis
• persistent acid reflux
• severe vomiting

Having a hiatal hernia is currently up for debate as to whether it’s a risk factor for Mallory-Weiss tears. While many who have a diagnosis of MWS have reported having hernias, it’s still unclear whether there’s a proven link.

MWS doesn’t always produce symptoms. This is more common in mild cases when tears of the esophagus produce only a small amount of bleeding and heal quickly without treatment.

In most cases, however, symptoms will develop. These may include:

• abdominal pain
• vomiting up blood, which is called hematemesis
• involuntary retching
• bloody or black stools

Vomiting blood

Blood in the vomit will usually be dark and clotted and may look like coffee grounds. Occasionally it can be red, which indicates it’s fresh.

Blood that appears in the stool will be dark and look like tar, unless you have a large bleed, in which case it will be red.

If you have these symptoms, seek immediate emergency care. In some cases, blood loss from MWS can be substantial and life threatening.

There are other health problems that may produce similar symptoms.

Symptoms associated with MWS may also occur with the following disorders:

• Zollinger-Ellison syndrome, which is a rare disorder in which small tumors create excess stomach acids that lead to chronic ulcers
• chronic erosive gastritis, which is inflammation of the stomach lining that causes ulcer-like lesions
• perforation of the esophagus
• peptic ulcer
• Boerhaave’s syndrome, which is a rupture of the esophagus due to vomiting

It’s worth noting that MWS is a rare condition, and can only be diagnosed by a doctor. If you exhibit symptoms it’s important to see your physician immediately in order to get a proper diagnosis.

Your doctor will ask you about any medical issues, including daily alcohol intake and recent illnesses, to identify the underlying cause of your symptoms.

If your symptoms indicate active bleeding in the esophagus, your doctor may do what’s called an esophagogastroduodenoscopy (EGD).

You’ll need to take a sedative and a painkiller to prevent discomfort during this procedure. Your doctor will insert a small, flexible tube with a camera attached to it, called an endoscope, down your esophagus and into the stomach. This can help your doctor see your esophagus and identify the location of the tear.

Your doctor will likely also order a complete blood count (CBC) to confirm the number of red blood cells. Your red blood cell count may be low if you have bleeding in the esophagus.

Your doctor will be able to determine if you have MWS based on the findings from these tests.

According to the National Organization for Rare Disorders, the bleeding that results from tears in the esophagus will stop on its own in about 80 to 90 percent of MWS cases.

Healing typically occurs in a few days and doesn’t require treatment. But if the bleeding doesn’t stop, you may need one of the following treatments.

Endoscopic therapy

You may need endoscopic therapy if the bleeding doesn’t stop on its own. The doctor performing the EGD can do this therapy. Endoscopic options include:

• injection therapy, or sclerotherapy, which delivers medication to the tear to close off the blood vessel and stop the bleeding
• coagulation therapy, which delivers heat to seal off the torn vessel

Extensive blood loss may require the use of transfusions to replace lost blood.

Surgical and other options

Sometimes, endoscopic therapy isn’t enough to stop the bleeding. So doctors use other ways of stopping it, such as laparoscopic surgery to sew the tear.

If you can’t undergo surgery, your doctor may use arteriography to identify the bleeding vessel and plug it to stop the bleeding.

Medication

Medications to reduce stomach acid production, such as famotidine (Pepcid) or lansoprazole (Prevacid), may also be necessary. However, the effectiveness of these medications is still under debate.

There isn’t a lot that can be done to completely prevent MWS. However, there are a few lifestyle and health measures you can take in order to lower your risk of having MWS or improve your prognosis if you receive a diagnosis of MWS.

To prevent MWS, it’s important to treat conditions that cause long episodes of severe vomiting. To do this, visit your doctor for treatment or seek help for eating disorders, such as bulimia.

Excessive alcohol use and cirrhosis can trigger recurring episodes of MWS. Consider limiting your alcohol consumption to lower your risk of MWS. If you have MWS, avoid alcohol and talk with your doctor about ways to manage your condition to prevent future episodes.

Mallory-Weiss Tear: Causes, Symptoms, Treatment

Severe and prolonged vomiting can result in tears in the lining of the esophagus. The esophagus is the tube that connects your throat to your stomach.

Mallory-Weiss syndrome (MWS) is a condition marked by a tear in the mucous membrane, or inner lining, where the esophagus meets the stomach.

Most tears heal within 72 hours without treatment, but Mallory-Weiss tears can cause significant bleeding. Depending on the severity of the tear, surgery may be necessary to repair the damage.

The most common cause of MWS is severe or prolonged vomiting. While this type of vomiting can occur with stomach illness, it also frequently occurs due to chronic alcohol use or bulimia.

Other conditions can result in a tear of the esophagus as well. These include:

• trauma to the chest or abdomen
• severe or prolonged hiccups
• intense coughing
• heavy lifting or straining
• gastritis, which is an inflammation of the lining of the stomach
• hiatal hernia, which occurs when part of your stomach pushes through part of your diaphragm
• convulsions

Receiving cardiopulmonary resuscitation (CPR) can also lead to a tear of the esophagus.

MWS is more common in males than in females. It occurs more often in people with alcoholism. According to the National Organization for Rare Disorders, people between the ages of 40 and 60 are more likely to develop this condition. However, there are cases of Mallory-Weiss tears in children and young adults.

There are a few predisposing factors that can put you at risk of Mallory-Weiss tears. These can include:

• heavy alcohol consumption
• bulimia nervosa diagnosis
• persistent acid reflux
• severe vomiting

Having a hiatal hernia is currently up for debate as to whether it’s a risk factor for Mallory-Weiss tears. While many who have a diagnosis of MWS have reported having hernias, it’s still unclear whether there’s a proven link.

MWS doesn’t always produce symptoms. This is more common in mild cases when tears of the esophagus produce only a small amount of bleeding and heal quickly without treatment.

In most cases, however, symptoms will develop. These may include:

• abdominal pain
• vomiting up blood, which is called hematemesis
• involuntary retching
• bloody or black stools

Vomiting blood

Blood in the vomit will usually be dark and clotted and may look like coffee grounds. Occasionally it can be red, which indicates it’s fresh.

Blood that appears in the stool will be dark and look like tar, unless you have a large bleed, in which case it will be red.

If you have these symptoms, seek immediate emergency care. In some cases, blood loss from MWS can be substantial and life threatening.

There are other health problems that may produce similar symptoms.

Symptoms associated with MWS may also occur with the following disorders:

• Zollinger-Ellison syndrome, which is a rare disorder in which small tumors create excess stomach acids that lead to chronic ulcers
• chronic erosive gastritis, which is inflammation of the stomach lining that causes ulcer-like lesions
• perforation of the esophagus
• peptic ulcer
• Boerhaave’s syndrome, which is a rupture of the esophagus due to vomiting

It’s worth noting that MWS is a rare condition, and can only be diagnosed by a doctor. If you exhibit symptoms it’s important to see your physician immediately in order to get a proper diagnosis.

Your doctor will ask you about any medical issues, including daily alcohol intake and recent illnesses, to identify the underlying cause of your symptoms.

If your symptoms indicate active bleeding in the esophagus, your doctor may do what’s called an esophagogastroduodenoscopy (EGD).

You’ll need to take a sedative and a painkiller to prevent discomfort during this procedure. Your doctor will insert a small, flexible tube with a camera attached to it, called an endoscope, down your esophagus and into the stomach. This can help your doctor see your esophagus and identify the location of the tear.

Your doctor will likely also order a complete blood count (CBC) to confirm the number of red blood cells. Your red blood cell count may be low if you have bleeding in the esophagus.

Your doctor will be able to determine if you have MWS based on the findings from these tests.

According to the National Organization for Rare Disorders, the bleeding that results from tears in the esophagus will stop on its own in about 80 to 90 percent of MWS cases.

Healing typically occurs in a few days and doesn’t require treatment. But if the bleeding doesn’t stop, you may need one of the following treatments.

Endoscopic therapy

You may need endoscopic therapy if the bleeding doesn’t stop on its own. The doctor performing the EGD can do this therapy. Endoscopic options include:

• injection therapy, or sclerotherapy, which delivers medication to the tear to close off the blood vessel and stop the bleeding
• coagulation therapy, which delivers heat to seal off the torn vessel

Extensive blood loss may require the use of transfusions to replace lost blood.

Surgical and other options

Sometimes, endoscopic therapy isn’t enough to stop the bleeding. So doctors use other ways of stopping it, such as laparoscopic surgery to sew the tear.

If you can’t undergo surgery, your doctor may use arteriography to identify the bleeding vessel and plug it to stop the bleeding.

Medication

Medications to reduce stomach acid production, such as famotidine (Pepcid) or lansoprazole (Prevacid), may also be necessary. However, the effectiveness of these medications is still under debate.

There isn’t a lot that can be done to completely prevent MWS. However, there are a few lifestyle and health measures you can take in order to lower your risk of having MWS or improve your prognosis if you receive a diagnosis of MWS.

To prevent MWS, it’s important to treat conditions that cause long episodes of severe vomiting. To do this, visit your doctor for treatment or seek help for eating disorders, such as bulimia.

Excessive alcohol use and cirrhosis can trigger recurring episodes of MWS. Consider limiting your alcohol consumption to lower your risk of MWS. If you have MWS, avoid alcohol and talk with your doctor about ways to manage your condition to prevent future episodes.

Symptoms, Causes and Treatments

Contents

• 1 Complications of Peptic Ulcers: Symptoms, Causes and Treatments
  • 1.1 What is peptic ulcer and how does it occur
    • 1.1.1 Definition of peptic ulcer
    • 1.1. 2 Causes of peptic ulcer
    • 1.1.3 Symptoms of peptic ulcer
  • 1.2 Main symptoms of peptic ulcer
    • 1.2.1 Stomach pain and appetite
    • 1.2.2 Vomiting and nausea
    • 1.2.3 Changes in the intestines
    • 1.2.4 General weakness
  • complications can occur with peptic ulcer
• 1.4 Complications of gastric and duodenal ulcers: bleeding
• 1.5 Ulcer perforation as a serious complication of gastric and duodenal ulcers
• 1.6 Complications of gastric and duodenal ulcers
  • 1.6.1 Stenosis of the pyloroduodenal zone
• 1.7 Pancreatitis as one of the possible complications of gastric and duodenal ulcers
• 1. 8 How to prevent complications of gastric and duodenal ulcers
• 1.9 Diagnosis of complications of peptic ulcer of the stomach and duodenum
• 1.10 Treatment of complications of gastric and duodenal ulcers
  • 1.10.1 Drug treatment
  • 1.10.2 Surgical treatment
  • 1.10.3 Dietary treatment
  • 1.10.4 Physiotherapy treatment
• 1.11 Related videos:
• 1.12 Q&A: 9 0004
• • 1.12.0.1 What are the symptoms of complications of gastric ulcer and duodenal ulcer may occur?
  • 1.12.0.2 What types of complications can occur in gastric and duodenal ulcers?
  • 1.12.0.3 What can lead to complications of peptic ulcer?
  • 1.12.0.4 Why are complications of gastric and duodenal ulcers dangerous?
  • 1.12.0.5 How are complications of gastric and duodenal ulcers treated?
  • 1.12.0.6 Can complications of gastric and duodenal ulcers be prevented?

Complications of peptic ulcer of the stomach and duodenum: symptoms, causes and methods of treatment. Find out how you can prevent complications and keep your gastrointestinal tract healthy.

Peptic ulcer of the stomach and duodenum is a common disease of the gastrointestinal tract. It is characterized by the formation of ulcers in the mucous membrane of the stomach and/or duodenum.

Ulcers can lead to serious complications that can be life-threatening. Some of these include bleeding, perforation (rupture) of the wall of the stomach or intestines, stenosis (narrowing) of the esophagus, and severe pain.

Fortunately, many of these complications can be prevented or treated if the condition is diagnosed and treated early. However, without treatment, complications can progress, causing serious problems for the patient.

In this article, we look at the most serious complications of gastric and duodenal ulcers and how they can be prevented and treated.

What is peptic ulcer and how does it occur

Definition of peptic ulcer

Peptic ulcer is a chronic disease of the stomach or duodenum when an ulcer forms on the mucous membrane. Ulcers can spread to deep tissues.

Causes of peptic ulcer

The main reason for the development of peptic ulcer is a metabolic disorder at the hormonal level. Due to hormonal imbalance, problems with the work of the intestines and stomach can lead to peptic ulcer. External factors such as smoking, alcohol abuse and stress also play a role.

Symptoms of peptic ulcer

Symptoms of peptic ulcer may include stomach pain, nausea after eating, vomiting, increased stomach acid and stool disturbance. Fatigue, apathy and weakness can also be noted. If you suspect a peptic ulcer, you should consult a doctor and undergo the necessary examination.

Main symptoms of peptic ulcer

Stomach pain and appetite

Peptic ulcer is characterized by pain in the stomach, which can be of varying intensity and duration. They usually appear after eating and can be described as burning or stinging. Patients may also experience a decrease in appetite and weight loss due to pain after eating.

Vomiting and nausea

Some patients suffer from vomiting and nausea, which may be accompanied by dizziness and general weakness. These symptoms mostly occur after eating and may be caused by excessive consumption of fatty and heavy foods, alcohol, or certain medications.

Changes in the bowel

Patients with peptic ulcer may experience changes in the bowel pattern, including constipation, diarrhea, and a feeling of fullness in the abdomen. They often feel discomfort in the stomach, which can be expressed as burning or numbness in the epigastric region.

General weakness

Peptic ulcer can also cause a general feeling of tiredness and weakness, which is associated with gastric dysfunctions and other related problems in the body. Weakening of the body can negatively affect the functioning of internal organs, as well as the emotional state of the patient.

Complications of peptic ulcer of the stomach and duodenum

What complications can occur with peptic ulcer

Peptic ulcer of the stomach and duodenum can lead to a number of serious complications that can pose a threat to the health and even life of the patient.

• Ulcer perforation – Ulcer rupture and penetration of stomach contents into the abdominal cavity. Symptoms include severe abdominal pain, vomiting, and tenderness. Urgent surgical care is required.
• Bleeding from ulcer – In 15-20% of cases of peptic ulcer, bleeding from the ulcer may occur. Symptoms include black stools and coffee grounds vomit. Urgent treatment is required, and sometimes surgery.
• Stenosis – narrowing of the lumen of the duodenum or stomach due to scar tissue. Symptoms include abdominal pain, nausea, vomiting, and morning vomiting attacks. Treatment may be conservative or surgical.
• Metastases is a rare complication in which ulcer cancer spreads to other organs. Symptoms depend on which organ is affected. Treatment may be surgery, chemotherapy, or radiation.

To prevent the occurrence of complications of peptic ulcer, it is necessary to consult a doctor in a timely manner, follow a diet and diet, stop smoking and minimize excessive alcohol consumption, and follow all recommendations prescribed by the doctor for the treatment of the disease.

Complications of peptic ulcer of the stomach and duodenum: bleeding

Peptic ulcer of the stomach and duodenum can cause various complications, one of which is bleeding. This is a dangerous condition that requires immediate medical attention.

Bleeding symptoms may include black, tarry stools and vomit containing blood. In case of heavy bleeding, signs of shock may appear: rapid pulse, pale skin and mucous membranes, sweating.

Treatment for peptic ulcer bleeding may include acid-reducing drugs, antibiotics to fight Helicobacter pylori infection, and drugs to stop bleeding.

For patients who experience ulcer bleeding, it is vital to seek medical attention. Timely treatment can prevent serious consequences such as hypovolemic shock and death from bleeding.

Ulcer perforation as a serious complication of gastric and duodenal ulcer

Peptic ulcer of the stomach and duodenum is a common problem that leads to ulcers on the walls of the gastrointestinal tract. One of the most serious complications is ulcer perforation, when the ulcer penetrates the wall of the organ and causes the spread of infection and inflammation in the abdominal cavity.

An ambulance must be called immediately to treat a perforated ulcer. If a perforated gastric or duodenal ulcer is suspected, the patient usually needs surgery. During the operation, the surgeon corrects the damage and cleans the abdominal cavity from infection and inflammation. After the patient receives medical attention, strict observation and regular treatment is necessary to prevent recurrence of ulcer perforation.

Complications of peptic ulcer of the stomach and duodenum

Stenosis of the pyloroduodenal zone

One of the dangerous complications of peptic ulcer of the stomach and duodenum is stenosis of the pyloroduodenal zone. This condition is characterized by narrowing of the lumen of the stomach and the beginning of the duodenum, which can lead to disruption of the passage of food and difficulty in digestion.

The main symptom of pyloroduodenal stenosis is pain in the upper abdomen after eating. Other symptoms may include vomiting, nausea, a feeling of fullness in the stomach, and decreased appetite.

Treatment of pyloroduodenal stenosis includes drugs to reduce inflammation and tissue narrowing, and procedures to widen the lumen. In more complex cases, surgery may be required.

Pancreatitis as one of the possible complications of gastric and duodenal ulcers

Gastric and duodenal ulcers can lead to various complications, including pancreatitis. Pancreatitis is an inflammatory disease of the pancreas that can be caused by a variety of factors, including exocrine and endocrine insufficiency, removal of the gallbladder, and other causes.

In patients with gastric and duodenal ulcers, inflammation of the pancreas can be caused by increased acidity in the stomach, as well as damage to the lining of the stomach and duodenum. This can lead to infiltration of pancreatic tissues and, consequently, to inflammation.

Symptoms of pancreatitis include acute or chronic abdominal pain, nausea, vomiting, and diarrhea. Patients may also experience fever and pain in the left side, as well as loss of appetite and weight loss. Long-term pancreatitis can lead to malfunction of the pancreas, which can cause digestive dysfunction and diabetes.

Treatment for pancreatitis due to peptic ulcer usually involves the use of enzyme preparations to help the body break down and absorb food more easily. In addition, patients may be prescribed anti-inflammatory therapy or surgery if pancreatitis is due to mechanical causes.

How to prevent complications of gastric and duodenal ulcers

Complications of gastric and duodenal ulcers can be very serious and dangerous. The ulcer itself can lead to severe pain, bleeding, perforation and other unpleasant consequences. However, there are several ways to prevent the development of these complications.

1. Follow a healthy diet. Limit fatty, spicy and acidic foods, alcohol, coffee and strong drinks. Prefer food rich in fiber, vitamins and minerals.
2. Monitor your medications. Some drugs, such as aspirin, proton pump inhibitors, and non-steroidal anti-inflammatory drugs, can harm the gastrointestinal tract. So if you have an ulcer, be sure to talk to your doctor about your medications and possible side effects.
3. Do not be nervous or stress your body. Nervous experiences and stress can worsen the condition of the gastrointestinal tract, which, in turn, can lead to complications of peptic ulcer disease. Try to relax and avoid stressful situations.
4. Seek medical attention at the first sign of symptoms. If you notice symptoms of an ulcer, such as abdominal pain, nausea, vomiting, etc., be sure to see a doctor. Early diagnosis and treatment of peptic ulcers can prevent complications.

Table: Products useful for the gastrointestinal tractProduct nameUseful properties

A healthy lifestyle, proper nutrition, regular check-ups and timely treatment of peptic ulcer can significantly reduce the risk of complications. Try to follow these simple rules and take care of your health!

Diagnosis of complications of peptic ulcer of the stomach and duodenum

Peptic ulcer of the stomach and duodenum is a disease characterized by the formation of ulcers on the mucous membrane of the digestive organs. Complications can occur at any stage of the disease, so it is important to diagnose them in a timely manner.

One of the main methods for diagnosing complications of peptic ulcer is gastroscopy , in which a thin flexible tube with a video camera is inserted into the stomach. This method allows you to see ulcers and determine their severity.

Another diagnostic method is fibrogastroduodenoscopy , which allows you to study the condition of the mucous membrane of the stomach and duodenum in more detail. This method allows you to identify complications such as bleeding or perforation in the wall of the stomach or intestines.

Capsule endoscopy is used to determine if an ulcer is bleeding, in which the patient swallows a capsule with a video camera and the image is transmitted to the doctor’s screen. This method allows you to identify small bleeding, which can lead to serious complications if not treated promptly.

• Gastroscopy – the main method for diagnosing complications of peptic ulcer
• Fibrogastroduodenoscopy – allows you to study the condition of the mucous membrane of the digestive tract
• Capsule endoscopy – checks for ulcer bleeding

It is important to seek medical attention if you develop symptoms of complications such as severe stomach pain, bloody vomit and stools, fever, pale skin, and decreased appetite. Timely diagnosis and treatment of complications of peptic ulcer will help to avoid serious complications and maintain the health of the patient.

Treatment of complications of gastric and duodenal ulcers

Drug treatment

Drug treatment is the main method of dealing with complications of peptic ulcer. For the treatment of ulcerative ulcers and hemorrhagic complications, drugs that reduce the acidity of the gastric juice, such as proton pump inhibitors and histamine receptor antagonists, are used.

In case of infection, treatment is carried out with antibiotics that destroy the bacterium Helicobacter pylori.

Surgical treatment

Surgical treatment is necessary in rare cases when conservative methods are useless. Operations are performed to remove an ulcer, or to remove the end segment of the stomach if it is damaged, or to remove recurrent ulcers.

Dietary management

Dietary management plays an important role in preventing the complications of peptic ulcer disease. Patients are advised to monitor their diet, excluding spicy, fatty and sour foods, as well as alcohol and soda from the diet.

• It is recommended to eat smaller portions of food, but more often;
• Eat slowly and carefully;
• Drink more fluids to dilute stomach acid;
• Avoid stress and psycho-emotional stress that can increase the acidity of gastric juice;
• Eat foods rich in vitamin C, which promotes healing of ulcers.

Physiotherapy treatments

Physiotherapy treatments such as electrolysis, UHF therapy and massage therapy can also help in the healing process of ulcers and prevent recurrence of complications.

Procedures Contraindications

Related videos:

Q&A:

What symptoms of gastric and duodenal ulcer complications can occur?

Complications of peptic ulcer may present with symptoms such as severe pain in the upper abdomen, vomiting, bloody stools, loss of appetite and weight. In case of acute bleeding from an ulcer, pallor of the skin, weakness, as well as a feeling of dizziness and fainting may develop.

What types of complications can occur with peptic ulcer of the stomach and duodenum?

Complications of peptic ulcer can be varied, including bleeding, perforation (breaking through the wall of the organ), stenosis (narrowing of the lumen of the organ), as well as other comorbidities associated with PUD, such as stomach cancer.

What can lead to the development of complications of peptic ulcer?

Complications can occur due to improper or untreated DU, alcohol abuse, smoking, stress, and comorbidities such as hypertension, diabetes, and digestive health problems.

Why are complications of gastric and duodenal ulcers dangerous?

Complications of peptic ulcer can lead to serious consequences, including death. For example, bleeding can lead to large blood loss and therefore shock. Perforation of the stomach or intestines can cause peritonitis, a dangerous inflammatory disease of the abdominal cavity that can be fatal.

How are complications of gastric and duodenal ulcers treated?

Treatment for complications of PUD may include surgery, medications, diet, and diet as directed by your doctor. Treatment should be individualized, depending on the specific case, taking into account age, general health, and the presence of concomitant diseases.

Is it possible to prevent the development of complications of peptic ulcer of the stomach and duodenum?

Yes, you can help prevent the development of complications by following the doctor’s recommendations for the treatment of DU, stopping the abuse of alcohol, smoking, and maintaining a healthy lifestyle. You should also pay attention to the symptoms of a peptic ulcer and seek the help of a doctor if necessary.

Heterotopy of the gastric mucosa in the proximal esophagus: a historical perspective and a modern view | Dolgushina A.I., Khikhlova A.O., Olevskaya E.R., Naumenko O.V.

Introduction

Heterotopia, i.e., atypical localization, of the gastric mucosa (GM) can occur in any part of the gastrointestinal tract (GIT), including the rectum and gallbladder. Heterotopic gastric mucosa in the upper esophagus, which is known in the English literature under the term “inlet patch”, is an island of ectopic mucosa, characteristic of the stomach, in the proximal esophagus at the level of the upper esophageal sphincter or several centimeters distal (Fig. 1, 2) [1]. In rare cases, heterotopia loci are found in all parts of the esophagus [2, 3].

For the first time, the case of finding glands containing parietal cells in the upper esophagus was described in 1805 by the pathologist Schmidt [1]. Thanks to the development of endoscopic technologies, the understanding of this problem has now been significantly expanded, but many issues still remain poorly understood. In particular, there is considerable disagreement among researchers about the frequency of inlet patches. So, according to autopsy data, gastric heterotopia in the proximal esophagus occurs in 0.7–70% of cases [1], according to endoscopic examination, the frequency also varies widely and ranges from 0.1% to 14.5% [4–6 ].

Information about the features of the development of esophageal heterotopia of the gastric mucosa depending on age and gender is ambiguous. H. Takeji et al. [1] believe that the lesion may regress with age and note its higher frequency in males. The works of other researchers do not show significant age and gender differences [7].

Pathogenesis and pathomorphology

The pathogenesis of gastric heterotopia in the upper third of the esophagus is unknown. Three hypotheses for the development of this pathology are proposed. Most authors are of the opinion about the innate origin of the “inlet patch” [8, 9]. At the 11th week of embryogenesis, the columnar epithelium is replaced by stratified squamous epithelium, spreading in the distal and proximal directions from the middle part of the esophagus, while the proximal part of the esophagus undergoes transformation last [8]. This theory is supported by the following facts: firstly, immunohistochemical analysis showed that heterotopia loci contain cells characteristic of embryonic GM [8, 10]; secondly, the prevalence of gastric heterotopia in the upper third of the esophagus does not increase with age, and, according to some data, is more common in children [8].

Another theory suggests an acquired pattern of metaplastic transformation of the squamous epithelium due to chronic acid exposure in gastroesophageal reflux, similar to the development of Barrett’s esophagus [11].

Rupture of retention cysts of glands in the epithelium of the proximal esophagus is considered as another option for the origin of GM heterotopia (Fig. 3, 4) [12].

Most often, the epithelium in the ectopic locus corresponds to the fundal and cardiac histological types, less often to the antral one (Fig. 5). In a study by U. Peitz et al. [6] noted that the cardiac type of epithelium is typical for small heterotopias, while the fundic type is more common in large heterotopias. Significantly, the “inlet patch” in the presence of parietal cells can produce some acid (Fig. 6) [13]. It should be noted that the anatomical proximity to the laryngeal mucosa and its high susceptibility to acid damage, even with weakly acidic secretion, can lead to symptoms. In addition, mucus production, even in the absence of acid, has been shown to induce laryngopharyngeal symptoms [14]. Hyperacidity can also induce chronic inflammation and ulceration of the esophageal mucosa around the ectopic gastric mucosa and is a rare cause of strictures. Morphologically, the “inlet patch” is often associated with inflammatory infiltration by granulocytes and plasma cells. Other histological changes include atrophy, metaplasia, dysplasia, and adenocarcinoma [8]. In 2004 B.H. von Rahden proposed a classification that made it possible to structure the morphological and clinical manifestations of GM heterotopia (Table 1) [2].

Sites of heterotopy can be colonized by Helicobacter pylori (Hp) [4]. The prevalence of helicobacteriosis in the foci of gastric mucosa ectopic in the esophagus reaches 82% [11]. Infection rates are likely to correlate with the prevalence of Hp infection in the general population. Although the role of HP in this situation remains unclear, it can be assumed that it can cause changes similar to those observed in the stomach: atrophy, metaplasia, dysplasia and carcinoma [8].

Diagnosis

The main method for diagnosing gastric heterotopia in the upper third of the esophagus is esophagogastroduodenoscopy (EGD) with biopsy. Unfortunately, heterotopic foci are often missed during endoscopy because the proximal esophagus is either ignored or scanned [15]. This fact probably explains the significant difference in prevalence data obtained from autopsy and endoscopic studies. With endoscopy, the coolant areas in the proximal esophagus are visualized as round or oval salmon-colored, velvety-looking spots, more often single, rarely paired and multiple. The surface may be smooth or grainy, flat or slightly raised. Infrequently, ectopic mucosal fluid is an area of ​​mucosal depression. Most inlet patches are located on the lateral walls, usually a few centimeters distal to the upper esophageal sphincter (16–21 cm from the incisors). The sizes can vary from microscopic to 3–5 cm (see Fig. 1, 2).

A number of studies show that narrow band imaging (NBI) endoscopy increases the detection rate of heterotopia by about 3 times compared with standard white light endoscopy (Fig. 7) [11, 16]. In a study by C.L. Cheng et al. [17], which included 99 patients with gastric heterotopia in the upper third of the esophagus, small foci of heterotopia were detected in 54% of the subjects using a narrow spectrum versus 17% detected in white light. These results allow us to confidently recommend the use of virtual chromoendoscopy for the diagnosis of “inlet patch” [16].

C. blanco et al. [15] proposed to use the frequency of detection of heterotopic areas in the proximal esophagus as a criterion for the quality of upper gastrointestinal endoscopy, similar to the adenoma detection rate (ADR) criterion for colonoscopy.

Clinical manifestations

Clinical manifestations in patients with esophageal heterotopia of the gastric mucosa are absent in most cases. The appearance of symptoms is due to laryngopharyngeal reflux (LPR) or complications associated with the “inlet patch” (perforations, strictures, fistulas, and neoplastic transformation).

The greatest difficulty for diagnosis is caused by patients with symptoms caused by LPR: dysphagia, odynophagia, regurgitation, hoarseness, discomfort in the throat, itching, burning, chronic cough, feeling of “coma” in the throat [18]. According to V. Chong et al. [8], clinical manifestations are present in 73.1% of patients with “inlet patch”, complaints of sore throat, hoarseness and heartburn dominate. In the works of J.S. Baudet et al. [19] and O.K. Poyrazoglu et al. [20] in the presence of gastric heterotopia, dysphagia is more common in patients, according to U. Weickert et al. [21] – recurrent hoarseness, dysphagia and heartburn. In a large study by W.L. Neumann et al. [22], which included a retrospective analysis 487 229In patients undergoing endoscopy, dysphagia, odynophagia, respiratory symptoms, and a feeling of “coma” were shown to be the most common symptoms [22]. The association of gastric mucosal heterotopia in the upper esophagus with chronic otitis and sinusitis, and bronchial asthma has been noted in the literature [8]. T. Talih et al. [23] suggested that gastric heterotopia in the upper third of the esophagus could cause retrosternal pain in a patient that mimics an attack of unstable angina requiring coronary angiography. Most researchers indicate the need for further research to explore the potential relationship of clinical symptoms with both the localization and/or size of the “inlet patch” and the morphological features of the heterotopic mucosa [8, 10, 24].

Heterotopic gastric mucosa and functional disorders of the gastrointestinal tract

Currently, there is no clear position regarding the nature of the relationship between esophageal heterotopia of the gastric mucosa and functional disorders of the gastrointestinal tract, primarily functional dyspepsia and non-erosive gastroesophageal reflux disease (GERD). It requires clarification to what extent the observed symptoms can be due to the presence of an “inlet patch” or attributed to manifestations of functional disorders. However, in certain categories of patients, informing about the presence of heterotopic gastric mucosa may help to calm them and reduce the severity of symptoms.

As one of the possible pathogenetic mechanisms for the onset of symptoms, alteration of the heterotopic GM by colonizing it with Hp is considered [10]. In addition, there is evidence of esophageal dysmotility in patients with “inlet patch” [13].

One of the most interesting symptoms is the sensation of a “coma” in the throat (globus sensation), which occurs in patients with an “inlet patch” with a frequency of 1.6–23.1% and is more common in women [10]. Such patients can be treated by psychiatrists for a long time, since it is widely known that globus sensation is considered a psychogenic problem [25]. The feeling of “lump” in the throat may be due to increased pressure in the upper esophageal sphincter (UES) due to the irritant action of the “inlet patch” or due to reflex contraction of the UES due to a respiratory defense mechanism, probably associated with reflux. In this case, the cause of the symptoms may be not only the production of acid by the cells of the “inlet patch”, but also the secretion of mucin [14]. This fact is confirmed by the presence of symptoms in patients with a cardiac type of heterotopic gastric mucosa and the absence of the effect of proton pump inhibitors (PPIs) in some patients. The significance of LPR symptoms is recognized by clinicians and has led to a change in the Rome IV criteria for functional gastrointestinal disorders. In the differential diagnostic list of conditions accompanied by a sensation of a “coma” in the throat, an “inlet patch” has been added [26].

Heterotopic gastric mucosa and Barrett’s esophagus

One of the topics for discussion is the association of esophageal heterotopia of the gastric mucosa with Barrett’s esophagus. A number of studies demonstrate the absence of a connection, while other authors state its presence [6, 22]. B. Avidan et al. [1] in a case-control study (53 patients with inlet patch and 4882 with no heterotopia) showed that Barrett’s esophagus was 4 times more common in patients with gastric heterotopia (34% versus 9%).

Heterotopic gastric mucosa and adenocarcinoma of the esophagus

The most serious issue is the study of the relationship between gastric heterotopia and adenocarcinoma of the esophagus. In a systematic literature review performed in 2017, M. Orosey et al. [27], described only 43 cases of adenocarcinoma in the proximal esophagus, which arose in the locus of gastric heterotopia, the vast majority of patients were male. The mean age of the patients was 63.6±11.3 years. Other authors also demonstrate a low incidence of neoplasia in the “inlet patch” – 0-1.56% [28]. Based on these data, in 2017 the British Society of Gastroenterology and the Association of Upper Gastrointestinal Surgery of Great Britain and Ireland concluded that the “inlet patch” does not require dynamic observation and routine biopsy [29]. Most studies show that the risk of malignant transformation of heterotopic GM into the esophagus does not depend on age, race, body weight and alcohol consumption, smoking is significant (23. 7 pack/years versus 16.3 pack/years, p=0.006) [30 ]. In 2019, French researchers [31] reported that among patients with a detected mutation in the CDh2 gene associated with a high risk of developing hereditary diffuse gastric cancer, an “inlet patch” was detected and morphologically verified in 50%. However, in this group of patients, not a single case of esophageal cancer was recorded against the background of the “inlet patch” [31]. Following this publication, P. Leclercq et al. [24] suggested that an islet of columnar epithelium in the upper third of the esophagus is a potential hazard for the development of adenocarcinoma in patients with CDh2 gene mutations, including those undergoing prophylactic gastrectomy, which necessitates targeted endoscopic examination with sampling of histological material of ectopic gastric mucosa in the proximal esophagus [24].

Treatment

A unified approach to the treatment of patients with esophageal heterotopia of the gastric mucosa has not been developed. Almost all authors are inclined to believe that asymptomatic gastric heterotopia of the esophagus does not require treatment [1]. If there are complaints, acid-suppressive PPI therapy is indicated to relieve symptoms caused by acid secretion. The duration of PPI prescribing is not clearly defined, but the tactics used in the treatment of GERD are considered justified: step-down or step-up therapy for 4–8 weeks, followed by PPI on demand. If, despite a high dose of PPI, there are relapses, the addition of H 9 antagonists0473 2 receptors in the evening can prevent nocturnal acid breakthrough. Interestingly, one study showed a decrease in the size of the heterotopia locus after a course of PPI [11].

The ineffectiveness of conservative measures is an indication for complete endoscopic or surgical removal of heterotopic foci, with endoscopic ablative methods being preferred.

In recent years, several publications have appeared on the use of radiofrequency ablation (RFA) for the treatment of gastric heterotopia in the proximal esophagus [32]. In 2015 R.H. Cartabuke reported successful endoscopic mucosal resection of an area of ​​high dysplasia in the “inlet patch” combined with RFA of the entire area of ​​heterotopy, located 19 to 22 cm from the incisors and covering 75% of the circumference of the esophagus. Follow-up examination after 6 months. showed complete eradication of the area of ​​heterotopia [18].

A. Meining et al. [33] studied the effect of argon plasma coagulation (APC) (coagulation power was 60 W, the argon flow rate was 2 l/min) on the relief of symptoms in 10 patients with heterotopic GM and complaints of a feeling of “coma” in the throat and/or a sore throat. The authors noted a significant improvement in the well-being of patients, the almost complete disappearance of these symptoms after 8 weeks. after treatment [33]. In a prospective randomized study of patients with similar complaints, M. Bajbouj et al. [14] showed that in 82% of patients who underwent APC, throat discomfort was significantly reduced, and in 90% endoscopically recorded complete disappearance of areas of heterotopia compared with the absence of such in patients in the control group [14]. At the next stage of the study after 27 months. observation APC was assessed as successful in 74% of patients [34]. In a meta-analysis of 6 studies on the use of APC in symptomatic patients with heterotopic gastric mucosa in the upper third of the esophagus, response to therapy was recorded in more than 80% of patients. The median follow-up time in these studies ranged from 1 month. up to 36 months [14].

In the presence of complications, such as strictures and fibrosis, a biopsy is indicated to exclude malignancy and conduct dilation. Y. Shimamura et al. [35] demonstrated a case of successful balloon dilatation of a proximal esophageal stricture caused by a 3 cm circular “inlet patch” in a 67-year-old patient with dysphagia.

The presence of dysplasia and cancer in the heterotopia locus requires the implementation of algorithms adopted in oncology, which provide for a combination of surgical intervention with chemoradiotherapy.

Endoscopic mucosal resection has been described in 1 case of high-grade dysplasia [18] and in 6 patients with early esophageal adenocarcinoma [36]. Two of these patients had no signs of disease for 12 months. and 31 months. observations, respectively.

Conclusion

The clinical significance of gastric heterotopia in the upper esophagus is not well understood. Improvement of endoscopic examination, targeted examination of the proximal part of the esophagus will clarify the frequency of esophageal “inlet patch”. The available data indicate an association of esophageal heterotopia of the gastric mucosa with symptoms of LPR, data on the association of “inlet patch” with functional disorders of the gastrointestinal tract and Barrett’s esophagus are contradictory. At present, approaches to the treatment of patients with esophageal GM heterotopia are being developed, including a wide range of modern endoscopic techniques. Attracting the attention of clinicians to this problem and conducting further research can serve as the basis for improving the treatment and diagnostic approaches to gastric mucosal heterotopia in the upper esophagus.