Article, Neurology

Intra-abdominal hemorrhage due to vigorous vomiting masked by the coexistence of Mallory-Weiss syndrome

Abdominal hemorrhage due to vigoro”>Fig. 2 Initial coronal Brain CT scan showing a bilateral frontal pneumocephalus.

embolism and death from brainstem herniation. There have also been reports of cerebral infarction with subsequent development of seizure disorder from a tension pneumocele. Such morbidity stresses the need for early identification and prompt treatment [5]. It is possible to see focal findings without Elevated intracranial pressure among cases in which there is prolonged development of the posttraumatic pneumocephalus, thereby suggesting compensation for pressure changes caused by Volume expansion. Neurologic deterioration has been associated with pneumatoceles of volumes as low as 25 mL of air under tension. In the case presented here, the patient was completely asymptomatic, which highlights the compensation capacity of the human brain. Nonetheless, it is relatively uncommon that such a young patient would remain asymptomatic with this extent of pneumocephalus [6]. In this asymptomatic case, the patient was managed conservatively, with bed rest and 100% oxygen therapy to wash out nitrogen and decrease intracranial gas.

Oliver P. Gautschi MD Rene’ Zellweger MD

Department of Orthopedic and Trauma Surgery

Royal Perth Hospital Perth, Western Australia 6000, Australia E-mail address: [email protected]

doi:10.1016/j.ajem.2005.12.021

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  3. Marras LC, Kalaparambath TP, Black SE, Rowed DW. Severe tension pneumocephalus complicating frontal sinus osteoma. Can J Neurol Sci 1998;25:79 – 81.
  4. Sherman SC, Bokhari F. Massive pneumocephalus after minimal head trauma. J Emerg Med 2003;25:319 – 20.

intra-abdominal hemorrhage due to vigorous vomiting masked by the coexistence of Mallory-Weiss syndrome

Mallory-Weiss syndrome is widely discussed since 1929. It was caused by forceful vomiting or retching usually after binge consumption of alcohol. Other reasons of vomiting include infectious gastroenteritis, Peptic ulcers, hiatal hernia, volvulus, hyperemesis of pregnancy, gallstone, cholecystitis, uremia, increase intracranial pressure, use of emetics, or various kind of intoxication. The clinical manifestations of Mallory-Weiss syndrome range from dyspepsia, abdominal pain, tarry stool passage, and hema- temesis to hypovolemic shock [1]. We report a rare case of intra-abdominal bleeding and hypovolemic shock after vigorous vomiting after bingeing, despite the simultaneous occurrence of Mallory-Weiss tear had been under control.

A 32-year-old man without any history of diabetes, hypertension, bleeding tendency, and gastrointestinal tract bleeding experienced emotional distress because of recent divorce; he consumed a large amount of wine since 7:00 pm to 10:00 pm and eventually suffered from severe Epigastric pain and vomiting. He visited the ED at about 11:18 pm that evening and reported no coffee-ground substance or bloody content in his vomitus. He denied any recent physical injuries because of trauma. Intravenous crystalloid fluid replacement and Intramuscular injection of 50 mg meper- idine were prescribed for his stabilizing his clinical condition and pain relief, respectively. Chest radiography and left decubitus view of abdominal x-ray revealed no signs of pneumoperitoneum because of hollow organ perforation. Laboratory findings included white blood cell count 8890/mL with 46.7% neutrophil, 45.3% lymphocyte, 8.0% monocyte, hemoglobin 14.9 g/dL, hematocrit 46.2%, platelet count 212 000/mL, blood glucose

148 mg/dL, creatinine 1.4 mg/dL, sodium 140 mEq/L, potassium 3.4 mEq/L, amylase 42 U/L, lipase 79 U/L, and ethanol level 133.03 mg/dL. His symptoms were improved after the supportive treatment mentioned hereinabove, and

he was discharged at about 7:00 am the other day.

References

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  2. Lewin W. Cerebrospinal fluid rhinorrhea in Closed head injuries. Br J Surg 1954;42:1 – 18.

Unfortunately, because of severe epigastric pain, he revisited the ED at about 10:45 am again. This time, his vital signs were stable with body temperature at 378C, pulse rate 107 beats per minute, respiratory rate 18 times per minute, and blood pressure 135/69 mm Hg. Panendoscopy was arranged and the endoscopic findings were (1) erosive duodenitis, blub, (2) mild hemorrhagic gastritis, (3) esophageal shallow

Fig. 1 Intra-abdominal hemorrhage due to vigorous vomiting was uncovered under computer-aided tomographic scanning.

active ulcer and mild esophagitis, and (4) severe hiatal hernia. Despite these relatively benign clinical findings, the patient’s condition deteriorated progressively in that in the afternoon, his epigastralgia persisted with obvious cold sweating and his blood pressure dropped to 90/56 mm Hg. Reevaluating blood tests revealed white blood cell count 13390/mL with 82.4% neutrophil, 10.1% lymphocyte, 7.5% monocyte, hemoglobin 9.6 g/dL, hematocrit 29.9%, plate- let count 181000/mL, glutamate oxaloacetate transaminase

24 U/L, glutamate pyruvate transaminase 12 U/L, pro- thrombin time 12 seconds (control 11.3 seconds), and activated partial thromboplastin time 24.8 seconds (control 30.5 seconds). abdominal sonography discovered an Abdominal mass that was suspected to be a huge hematoma. Abdominal computed tomography scan was arranged to further confirm and delineate the sonographic image, its subsequent findings being hemoperitoneum (as shown in Fig. 1). Resuscitation with crystalloid solution and blood transfusion were done simultaneously to stabilize the patient’s condition. Initially, angiography to locate the intra-abdominal bleeding source and transarterial emboliza- tion for hemostasis was suggested; however, after thorough discussion with the patient’s family members, we arrived at the final decision in performing direct exploratory laparot- omy. The surgical finding was active bleeding due to tearing of the lesser Gastric artery in the gastrosplenic ligament, up to 1500 mL inside the peritoneal cavity. The operation was successful, and the patient was discharged uneventfully 10 days afterward.

Mallory-Weiss syndrome is commonly presented as hematemesis, epigastralgia, chest pain, and cold sweating in most clinical settings [2,3]. Occasionally, some cases result in hypovolemic shock. The most common compli- cations are esophageal tear, esophagitis, and gastritis, but rarely does it cause Esophageal hematoma [4], hollow organ perforation, or intra-abdominal bleeding, as seen in our reported case. Our Initial diagnosis for this case was

undoubtedly Mallory-Weiss syndrome because of vigorous vomiting after bingeing. In spite of endoscopic examina- tion of esophageal ulceration only without active bleed- ing, hypovolemic shock was subsequently noted. Intra- abdominal hemorrhage was eventually uncovered under sonographic and computer-aided tomographic examina- tions (Fig. 1). Laparotomic exploration revealed the bleeding source as tearing of lesser gastric artery. There are only very few examples in the literature that report esophagus hematoma caused by vigorous vomiting with the clinical manifestations of palpitation and chest pain. We learned a lesson from this case: despite that esophageal ulceration is found under endoscopic exami- nation, persistent epigastralgia, progressive pallor, and hypovolemic shock signs of the patient who experiences vigorous vomiting or retching should arouse high index of suspicion to look for an occult bleeding source inside the abdominal cavity. For example, massive intra-abdom- inal hemorrhage from a hepatic laceration caused by vomiting was reported by Horvath and Glasgow [5]. early use of sonographic or tomographic means to detect for intra-abdominal fluid is crucial in excluding any possibility of life-threatening internal bleeding. As a conclusion, even if Mallory-Weiss syndrome has been established under endoscopic examination, we should bear in mind not to miss the possibility of simultaneous occurrence of intra-abdominal hemorrhage because of blood vessel tearing caused by vigorous vomiting or retching when hypovolemic status persists after endoscop- ic exclusion of gastrointestinal tract bleeding.

Yen-Shuo Tsai MD Chi-Wei Lee MD

Department of Emergency Medicine E-Da Hospital/I-Shou University

Kaohsiung County 824 Taiwan, ROC

E-mail address: [email protected] doi:10.1016/j.ajem.2005.12.019

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