Systematic Reviews
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 7, 2016; 22(1): 446-466
Published online Jan 7, 2016. doi: 10.3748/wjg.v22.i1.446
Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis
Borko Nojkov, Mitchell S Cappell
Borko Nojkov, Mitchell S Cappell, Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
Borko Nojkov, Mitchell S Cappell, Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, United States
Author contributions: Nojkov B and Cappell MS designed research, performed research, analyzed data, and wrote the paper; both authors read and approved the final manuscript; both authors contributed equally to the paper.
Conflict-of-interest statement: None for all authors. This paper does not discuss any confidential pharmaceutical data reviewed by Dr. Cappell as a consultant for the United States Food and Drug Administration (FDA) Advisory Committee on Gastrointestinal Drugs. Dr. Cappell is a member of the speaker’s bureau for AstraZeneca. This work does not discuss any drugs produced or marketed by AstraZeneca.
Data sharing statement: No additional data available for this systematic review.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Mitchell S Cappell, MD, PhD, Division of Gastroenterology and Hepatology, William Beaumont Hospital, MOB 602, 3535 W. Thirteen Mile Road, Royal Oak, MI 48073, United States.
Telephone: +1-248-5511227 Fax: +1-248-5515010
Received: July 29, 2015
Peer-review started: July 30, 2015
First decision: August 31, 2015
Revised: September 11, 2015
Accepted: November 24, 2015
Article in press: November 24, 2015
Published online: January 7, 2016

AIM: To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy’s lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis.

METHODS: Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: “alcoholic liver disease”, “alcoholic hepatitis”,“ alcoholic cirrhosis”, “cirrhosis”, “liver disease”, “upper gastrointestinal bleeding”, “non-variceal upper gastrointestinal bleeding”, “PUD”, ‘‘DL’’, ‘‘Mallory-Weiss tear”, and “MWS’’.

RESULTS: While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population.

CONCLUSION: Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS.

Keywords: Alcoholic liver disease, Alcoholic hepatitis, Cirrhosis, Portal hypertension, Peptic ulcer disease, Mallory-Weiss syndrome, Dieulafoy lesion, Endoscopic therapy

Core tip: Alcoholism is highly prevalent worldwide and can cause advanced-alcoholic-liver-disease (aALD) from alcoholic hepatitis or cirrhosis. This work systematically reviews the literature on acute-upper-gastrointestinal-bleeding not directly related to portal hypertension in patients with aALD. Such patients have markedly increased risks of peptic ulcers, and worse outcomes from peptic ulcer bleeding than other patients, including refractory bleeding, rebleeding, and mortality. Such patients apparently have increased frequency and mortality of bleeding from Dieulafoy lesions. Such patients have more frequent, more severe, and more rebleeding from Mallory-Weiss-syndrome than non-cirrhotics. Prompt endoscopy, after resuscitation, is essential to diagnose and appropriately treat these patients, using endoscopic therapy when necessary.