Mallory-Weiss Tear and Pulmonary Mets

Thank you Chuka and Lauren for presenting 2 twin cases today:

1) Case 1 was of a young man who presented with an acute onset of emesis with progression to bloody emesis, melena, and significant anemia, following a trip to the Carribean. We discussed the differential for acute diarrhea in a returned traveler (including possibility EHEC and risk for hemolytic-uremic syndrome). He was ultimately diagnosed with a Mallory-weiss tear, likely in the setting of acute retching secondary to presumed viral gastroenteritis.

2) Case 2 was a case of an elderly woman presenting with constitutional symptoms & a mechanical fall, who was found to have a large pulmonary mass, that was thought to be a met from new gastric cancer. ____________________________________________________________________________________

TOP PEARLS

  • Pulmonary metastatic lesions tend to have proclivity for the lung bases, are subpleural in location, and have sharply demarcated borders (there are exceptions, however!)
  • HUS is a rare but potentially fatal complication of E. Coli O157:H7 infection!
  • Not all Mallory-weiss tears bleed, but when they do, upto 70% of them will require blood transfusions.

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Mallory-Weiss Tear

  • Mallory-Weiss tears are longitudinal, mucosal lacerations in the distal esophagus & proximal stomach, usually associated with forceful retching.
  • Not all tears bleed, but bleeding involves underlying esophageal venous or arterial plexus; 40-70% patients with bleeding Mallory-weiss tears require blood transfusions (think, brisk, arterial bleeding!)
  • Predisposing conditions:
    • Hiatal hernia: a higher pressure gradient develops in the hernia during retching, increasing the potential for mucosal laceration
    • Alcoholism-induced vomiting
    • Age: although age has been proposed as a predisposing condition, most MW tears occur in patients < 40 yoa
  • Treatment: epinephrine injection, electrocoagulation (thermal therapy), endoscopic band ligation

Radiographic findings of Pulmonary Metastases

  • Note, in a patient with a history of extrathoracic malignancy, the probability of metastasis is ~25% when a solitary pulmonary nodule is detected on CXR.
  • Common cancers that metastasize to the lungs: Bladder, Breast, colon, RCC, Melanoma, Ovarian, Sarcoma, Thyroid
  • In general, they have a proclivity for the lung bases and tend to be subpleural in location.
  • Usually, metastastic lesions are round with sharply demarcated borders, but mets that tend to hemorrhage (choriocarcinoma, RCC, melanoma, thyroid, Kaposi’s) may have indistinct borders and have a ground-glass opacity look.
  • Cavitation rarely happens (<5 %) and is preferentially seen in squamous cell carcinoma

Hemolytic Uremic Syndrome associated with E. Coli O157:H7 infection

  • Characterized by MAHA, thrombocytopenia, and acute renal injury. Rare neurologic complications can also occur.
  • 6-9% of STEC (Shiga-Toxin secreting E. Coli) infections
  • Pathophysiology 1) Shiga toxin released by E. coli binds to globotriaosylceramide (Gb3) on surface of vascular endothelial cells, particularly in the kidney and brain à inhibits protein synthesis à induces broad inflammatory response à releases cytokines and chemokines à thrombosis and organ damage! 2) Shiga toxin also activates alternative pathway of complement system by binding to factor H proteins!
  • Treatment
    • Best approach: Basic supportive care
    • Under investigation but not standard-of-care:
      • PLEX: remove Shiga-like toxin and prothrombotic factors and replace them with coagulation, tissue, and complement factors
      • Oral Shiga toxin-binding agent
      • Eculizumab: Monoclonal antibody to C5 complement factor blocking complement activation. There are case series demonstrating the benefit of using eculizumab in children with STEC-HUS

Filed under: Morning Report

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