Should a 56-year-old patient with a 30-year history of smoking, 6 days post-operative from abdominoplasty and liposuction (lipo), with a recent hemoglobin level improvement from 7.2 to 8 after iron infusion, suspected Mallory-Weiss tear, and recent vomiting, undergo endoscopy?

Should Endoscopy Be Performed on This Patient?

Yes, proceed with endoscopy now, but only after correcting electrolyte abnormalities (particularly potassium) and ensuring hemodynamic stability, with the procedure performed by an experienced endoscopist using CO2 insufflation. 1

Rationale for Proceeding with Endoscopy

Hemoglobin Status is Adequate

• Your patient's hemoglobin of 8 g/dL meets the threshold for safe endoscopy in the post-operative setting. 2, 3
• The transfusion threshold for most patients is 7-8 g/dL, and your patient is above this level. 3
• While hemoglobin >10 g/dL (100 g/L) is preferred for discharge criteria, a level of 8 g/dL is sufficient to proceed with diagnostic and therapeutic endoscopy once hemodynamically stable. 2, 3

Mallory-Weiss Tears Require Risk Stratification

• Mallory-Weiss tears account for 3-15% of upper GI bleeding cases, and most stop bleeding spontaneously (87.5% achieve primary hemostasis). 4, 5, 6
• However, endoscopy is essential to determine if active bleeding, a visible vessel, or adherent clot is present—these high-risk stigmata require immediate endoscopic therapy. 1, 2, 4
• If the tear is not actively bleeding and has no visible vessel, the rebleeding risk is very low and no further treatment is needed. 4
• The timing is critical: endoscopy should be performed within 24 hours of presentation in patients with significant bleeding once stabilized. 2, 7

Post-Operative Context Supports Early Endoscopy

• Endoscopic approaches should be considered regardless of time interval from surgery, including the immediate post-operative period. 1
• Persistent upper GI bleeding is a common indication for early post-operative endoscopy and can be safely performed. 1
• Your patient is 6 days post-op, which is well beyond the immediate post-operative period, making endoscopy even safer. 1

Critical Pre-Procedure Requirements

Electrolyte Correction is Mandatory

• Patients with severe and persistent vomiting who are about to undergo emergent general anesthesia for endoscopy MUST be tested and treated for potassium deficiency. 1
• This is particularly important because paralysis during anesthesia in the setting of hypokalemia can precipitate life-threatening arrhythmias. 1
• Also screen for thiamine deficiency and consider prophylactic treatment, as Wernicke's encephalopathy has been reported in post-operative patients with complications. 1

Hemodynamic Stability Must Be Achieved First

• Endoscopy should only be performed when resuscitation has been achieved—never delay resuscitation to perform endoscopy. 1
• Blood pressure should be stable (systolic BP >100 mmHg, pulse <100 bpm ideally), though in actively bleeding patients this is not always possible. 1, 2
• Your patient's hemoglobin improved from 7.2 to 8 after iron infusion, suggesting bleeding has slowed or stopped, which is favorable. 3

Technical Considerations for the Procedure

Use CO2 Insufflation

• When endoscopy is performed in the post-operative setting, CO2 should be used for insufflation rather than air. 1
• This minimizes pressure along fresh surgical sites and reduces the risk of complications. 1

Experienced Endoscopist Required

• The procedure should be performed by an experienced endoscopist capable of therapeutic hemostasis. 1, 2
• If the interventional endoscopist lacks extensive experience with post-operative scenarios, perform the endoscopy in the operating room with a surgeon present (preferably the surgeon who performed the abdominoplasty). 1

Aspiration Risk in This Patient

• Given the 30-year smoking history and recent vomiting, consider endotracheal intubation before endoscopy to prevent pulmonary aspiration. 1
• Cardiopulmonary events account for >50% of endoscopy complications, with aspiration being a major risk. 1
• Continuous ECG monitoring and supplemental oxygen are mandatory given the smoking history and potential pulmonary compromise. 1

Expected Endoscopic Findings and Management

If Active Bleeding or High-Risk Stigmata Present

• Therapeutic intervention is indicated for active bleeding (spurting or oozing), non-bleeding visible vessel, or adherent blood clot. 1, 2
• Multipolar electrocoagulation (MPEC) has the best evidence-based support for safety and bleeding control in Mallory-Weiss tears. 4
• Alternative effective therapies include endoscopic band ligation (emerging as safe and effective), hemoclipping, or epinephrine injection (though avoid epinephrine if coronary artery disease is present). 4, 5

If No Active Bleeding

• If the tear is not actively bleeding at endoscopy and has no visible vessel, no further treatment is needed due to low rebleeding risk. 4, 8
• The patient can be managed conservatively with proton pump inhibitors and antiemetics. 5

Common Pitfalls to Avoid

• Do not delay endoscopy beyond 24 hours once the patient is stabilized—your patient is already 6 days post-op with ongoing anemia. 2, 7
• Do not proceed without checking and correcting potassium levels first. 1
• Do not perform endoscopy before adequate resuscitation—stabilization must precede diagnostic measures. 1, 2
• Do not use excessive crystalloid volumes that could exacerbate bleeding by disrupting clot formation. 7

Post-Procedure Monitoring

• Monitor for 4-6 hours post-endoscopy with continuous observation of pulse, blood pressure, and urine output. 3
• If low-risk findings are confirmed (clean-based tear with no stigmata), the patient can be considered for discharge once hemoglobin is >10 g/dL and hemodynamically stable for the observation period. 3