Answer
From question on page 364
CT disclosed an intact oesophagus and aorta. However, extravasation of the contrast agent was noted in the gastric cardia (fig 1 in question section). Subsequent gastroscopy disclosed a 1.5 cm Mallory–Weiss tear over the gastric cardia with active bleeding (fig 1).
Figure 1 Endoscopic image showing laceration of the gastric mucosa and active bleeding from a disrupted vessel (arrow).
Henry Heimlich first described his life‐saving manoeuvre to dislodge aspirated food from the upper airways in 1974. Since then, this manoeuvre has saved thousands of lives. Less emphasised are the complications of the Heimlich manoeuvre. Dr Heimlich initially described rib fracture as the most common complication. Subsequently, a wide variety of injuries such as rupture of the oesophagus, stomach, jejunum, aortic valve cusp, thrombosis of abdominal aortic aneurysm, mesenteric laceration and pneumomediastinum have been described. Increased intra‐abdominal pressure exerted during the Heimlich manoeuvre has resulted in several cases of gastric perforation and, to a lesser extent, a Mallory–Weiss tear as in this case.
The diagnosis of a Mallory–Weiss tear is usually made on the basis of case history and an endoscopic examination. In cases such as this, a CT examination should be performed before endoscopic examination to exclude organ perforation or injury to the aorta associated with the Heimlich manoeuvre. Endoscopic treatments, including haemoclips, electrocoagulation, a rubber‐band ligation or an injection of vasoconstrictors or sclerosants have been widely used to treat bleeding Mallory–Weiss tears. Successful haemostasis was achieved in this case with electrocoagulation (fig 2) and the patient recovered without complications, as evidenced during a 3‐month follow‐up period.
Figure 2 Endoscopic image showing haemostasis after electrocoagulation and several submucosal vessels (arrows).