mallory  weiss tears ( mwts ) account for 614% of upper gastrointestinal bleeding ( ugib ) . three weeks prior , she sustained a flail chest , right hemothorax , splenic laceration , mesenteric injury , and lumbar and thoracic vertebral fractures in a motor - vehicle accident . significant hematemesis occurred 4 days after admission to the rehabilitation ward , and the patient was transferred to the intensive care unit ( icu ) , where a gastroscopy was performed . a large clot was observed in the fundus ; however , there was no active bleeding . a sengstaken  blakemore ( sb ) tube was inserted and the gastric balloon inflated under endoscopic vision , and 6 units of packed red blood cells , 4 units of fresh frozen plasma , 2 units of platelets and 10 units of cryoprecipitate were transfused . hemodynamic stabilization was achieved , and serum hemoglobin rose from 61 to 89 g / dl . a repeat gastroscopy the following day demonstrated the fundal clot plus a large mwt at gastroesophageal junction ( gej ) ( fig .  1 ) . adrenaline ( 1:10 000 ) was injected around the tear , and the sb tube was removed . the patient subsequently developed a pulmonary embolism , which was treated with an inferior vena caval filter . on day 5 after transfer to the icu hematemesis recurred on day 8 , and the patient was intubated because of hemodynamic instability . gastroscopy was performed after massive transfusion resuscitation , and the large fundal clot and mwt were again noted . hemostatic powder ( endoclot ) was applied over the probable location of the fundal ulcer as well as mwt though there was no active bleeding . figure  1:a large mallory  weiss tear and large fundal clot were observed during gastroscopy . a large mallory  weiss tear and large fundal clot were observed during gastroscopy . gastroscopy the following day showed a fundal gastric ulcer and the mwt , which was now larger and deeper ( fig .  2 ) . on day 10 , after the anterior wall of the stomach was exposed from the gej to pylorus , a longitudinal gastrotomy was created over the fundus . there was a deep mwt at gej extending along the greater curve of the stomach , which was bleeding actively . the mwt was oversewn with interrupted 3/0 pds sutures and hemostasis achieved . a second , larger fundal ulcer , presumably from pressure necrosis of sb tube , was also noted . this ulcer occupied most of the fundus of stomach , which was excluded from the gastric cavity , by the closure of fundus with interrupted 3/0 pds ( fig . figure  2:during the last gastroscopy , a fundal gastric ulcer and a larger and deeper mallory figure  3:the gastric ulcer was excluded from the rest of the stomach through gastrostomy using 3/0 pds suture . during the last gastroscopy , a fundal gastric ulcer and a larger and deeper mallory the gastric ulcer was excluded from the rest of the stomach through gastrostomy using 3/0 pds suture . recent national audits from the uk and usa reported annual incidences of ugib of 50150 per 100 000 adults , with mortality rates of 2.510% [ 1 , 3 ] . mwt is relatively common , and intervention is rarely required . currently , mwt is predominantly managed by observation and if necessary , gastroscopy and various advanced endoscopic techniques , including endoscopic diathermy , local adrenaline injections , local hemostatic agents , and endoscopic clips . surgery is generally reserved for refractory bleeding and failed endoscopic management , and as such is rarely performed [ 5 , 6 ] . in our patient , multiple endoscopies were performed with various techniques , including sb tube insertion , local adrenaline injection , bipolar electrocoagulation , and hemostatic powder ( endoclot ) application by our experienced gastroenterologist . although sb tube was appropriately managed based on the institutional protocol , the mwt became complicated with a large gastric ulcer . despite extensive efforts , bleeding remained uncontrolled and the mallory nevertheless , the second fundal ulcer due to sb tube posed a significant challenge because of its size and anatomical location . oversewing bleeding point of ulcer or ulcer excision are principles of surgical treatment and prevention for bleeding ulcer with the use of ppi . in our case , the decision that a gastrectomy was deemed intolerable was due to difficult anatomy including adhesions and inflamed and fibrotic surrounding tissue , the clinical course , and the patient 's compromised condition . the gastric ulcer exclusion that we performed in this case was the exclusion of ulcer internally from the gastric cavity with absorbable sutures . it was thought that hemostasis for refractory bleeding might have been achieved since it would have caused tamponade effects by itself , as well as protected from oral intake and acid production , combined with ppi . gastric exclusion was initially described by waddell et al . in 1957 , in the surgical treatment of duodenal ulcer . our exclusion technique is a different surgery , a temporary measure , potentially reversible and less physiologically demanding . since the evolution of endoscopy and the advent of ppi therapy , the surgical management for ugib has been almost completely substituted by the endoscopic interventions except for the rare event where hemostasis could not be achieved endoscopically . this report describes , to our best knowledge , the successful performance of complex surgical management , including the first gastric ulcer exclusion , for recurrent bleeding from a mwt and associated ulcer . furthermore , this case highlights not only the importance of conventional surgical technique and established knowledge but also the timely manner of surgical decisions in a physiologically complex patient . this exclusion strategy may be applicable for other patients with uncontrolled ugib in whom a simple repair would be difficult .
mallory 
 weiss tears ( mwts ) rarely require surgical intervention . a 60-year - old female presented with massive hematemesis secondary to mwt and gastric ulceration . 
 after failure of endoscopic management , an operative approach was embarked on , with a direct surgical hemostasis of the mallory  weiss tear and exclusion of the gastric ulcer . 
 this exclusion strategy may be applicable for other patients with uncontrolled upper gastrointestinal bleeding in whom a simple repair would be difficult .