Snapshot A 54-year-old man with a history of alcoholism presents to the emergency room with hematemesis. He has a known history of esophageal and gastric varices and has been on beta-blockers to prevent bleeding. On physical exam, he is hypotensive and tachycardic. He has hepatosplenomegaly, ascites, and spider angiomata. He is started on a proton pump inhibitor as well as octreotide. He continues to vomit bright red blood. He is taken urgently for an EGD which showed bleeding from dilated esophageal veins, which is treated with sclerotherapy with good success. He is admitted to the ICU for further monitoring. Introduction Overview esophageal and gastric varices result as collateral system often secondary to portal hypertension often, these varices may present as acute gastrointestinal bleeding Associated conditions medical conditions and comorbidities hepatic encephalopathy ascites bacterial peritonitis primary biliary cirrhosis Budd-Chiari syndrome Epidemiology Incidence 50% of patients with cirrhosis Risk factors liver disease cirrhosis hepatitis C alcohol use NSAIDs coagulopathy splenic venous thrombosis ETIOLOGY Pathogenesis mechanism varices often develop in patients with portal hypertension varices offer a channel that diverts pressure from portal circulation to systemic circulation login to view 2 more bullets Presentation Symptoms common symptoms presentation depends on rate of gastrointestinal (GI) blood loss login to view 4 more bullets Physical exam inspection signs of liver disease login to view 6 more bullets IMAGING Esophagogastroduodenoscopy (EGD) indications all patients with GI bleed diagnostic and can be therapeutic findings abnormal venous dilation Studies Serum labs hemoglobin and hematocrit platelet count Differential Peptic ulcer disease key distinguishing factor EGD shows ulcers rather than abnormal venous dilation Treatment Medical resuscitation indication login to view 1 more bullet modalities login to view 2 more bullets somatostatin analogs indication login to view 1 more bullet drugs login to view 2 more bullets antibiotic prophylaxis indications login to view 2 more bullets drugs login to view 2 more bullets beta-blockers indications login to view 3 more bullets isosorbide mononitrate indications login to view 3 more bullets Surgical EGD indications login to view 2 more bullets modalities login to view 2 more bullets transjugular intrahepatic porto-caval shunt (TIPS) procedure indication login to view 1 more bullet complication login to view 1 more bullet Complications Variceal bleeding Hepatic encephalopathy Hepatorenal syndrome