Correspondence

Diagnosing Mallory-Weiss in the ED

To the Editor,

We read with interest the article by Dr Tsai [1] in the American Journal of Emergency of Medicine. The authors describe a 32-year-old man who presented with intra- Abdominal hemorrhage and Mallory-Weiss syndrome. Mallory-Weiss syndrome refers to mucosal laceration at the gastroesophageal junction or gastric cardia [2]. upper endoscopy is now the best tool to diagnose Mallory-Weiss syndrome that typically presents as a cleft-like mucosal defect. Most of the patients are brought to attention because of gastrointestinal bleeding. Excessive alcohol consumption is usually the culprit of Mallory-Weiss syndrome. Many other factors have been associated with it, including coughing, pregnancy, heavy lifting, straining, blunt abdominal trauma, colonic lavage, or cardiopulmonary resuscitation.

As an endoscopist, it would have been useful to know the nature of the esophageal ulcers described in this case to reliably establish the diagnosis of Mallory-Weiss syndrome. In addition, in a case with a rapidly deteriorating course after the endoscopic examination, one wonders about the impact of possible sedation during the endoscopic examination. Although uncommon, Mallory-Weiss tear is also a well- known complication of upper endoscopy with an estimated incidence of 0.07% to 0.49% [2,3]. If this case had a history of struggling or retching during the procedure, one should also consider the possibility of Iatrogenic injury based on the clinical course.

The authors also mention about esophageal hematoma with clinical manifestation of palpitations and chest pain. Typical symptoms of esophageal hematoma are chest pain, dysphagia, and hematemesis [4]. It is considered an inter- mediate stage in the spectrum from Mallory-Weiss tear to Boerhaave syndrome. Palpitation is an infrequent symptom. This condition should be differentiated with acute myocardial infarction and aortic dissection in the emergency department.

Hsu-Heng Yen MD Yang-Yuan Chen MD Department of Gastroenterology

Changhua Christian Hospital Changhua, Taiwan, ROC

E-mail address: [email protected] doi:10.1016/j.ajem.2009.07.012

References

1. Tsai YS, Lee CW. intra-abdominal hemorrhage due to vigorous vomiting masked by the coexistence of Mallory-Weiss syndrome. Am J Emerg Med 2006;24(5):629-30.
2. Younes Z, Johnson DA. The spectrum of spontaneous and iatrogenic esophageal injury: Perforations, Mallory-Weiss tears, and hematomas. J Clin Gastroenterol 1999;29(4):306-17.
3. Eisen GM, Baron TH, Dominitz JA, et al. Complications of upper GI endoscopy. Gastrointest Endosc 2002;55(7):784-93.
4. Yen HH, Soon MS, Chen YY. Esophageal intramural hematoma: an unusual complication of endoscopic biopsy. Gastrointest Endosc 2005;62(1):161-3.

Phentermine cardiovascular safety

To the Editor,

A recent case report published in the American Journal of Emergency Medicine [1] described a 48-year-old woman with no significant medical history who developed a myocardial infarction and subsequent ventricular tachycar- dia/fibrillation. This patient also happened to be taking phentermine, and the authors therefore conclude “that this agent, which is a chemical analogue of the potent amphetamine class of noradrenergic stimulants, may have the ability to promote potentially fatal cardiac outcomes.” We believe that the authors have left the reader with an unbalanced and exaggerated impression that phentermine is a dangerous drug. Because phentermine is commonly prescribed for the treatment of obesity, emergency medicine specialists deserve a more accurate discussion of the pharmacology and safety of phentermine.

To begin with, the risk posed by any medication is

best determined by careful long, multiyear randomized

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