Updated: 12/13/2021

Esophageal/Gastric Varices

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  • 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
          • results from increased vasodilation of gastric and esophageal vessels and vasoconstriction of intrahepatic vessels
          • often found in lower 1/3 of the esophagus and can extend into gastric veins
  • Presentation
    • Symptoms
      • common symptoms
        • presentation depends on rate of gastrointestinal (GI) blood loss
          • hematemesis
          • coffee-ground emesis
          • melena
          • hematochezia
    • Physical exam
      • inspection
        • signs of liver disease
          • spider angiomata
          • caput medusae
          • palmar erythema
          • gynecomastia
          • hepatosplenomegaly
          • telangiectasias
  • 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
          • acute variceal hemorrhage
        • modalities
          • intravenous fluids
          • blood transfusions to maintain hemoglobin > 8 g/dL
      • somatostatin analogs
        • indication
          • acute variceal hemorrhage
        • drugs
          • octreotide
          • vapreotide
      • antibiotic prophylaxis
        • indications
          • acute variceal hemorrhage
          • cirrhosis
        • drugs
          • ciprofloxacin
          • ceftriaxone
      • beta-blockers
        • indications
          • after acute episode of variceal hemorrhage
          • reduces rebleeding rate and mortality
          • secondary prophylaxis of bleeding
      • isosorbide mononitrate
        • indications
          • after acute episode of variceal hemorrhage
          • adjuvant with beta-blockers
          • venodilator
    • Surgical
      • EGD
        • indications
          • for all patients
          • diagnostic and therapeutic
        • modalities
          • endoscopic ligation
          • sclerotherapy
      • transjugular intrahepatic porto-caval shunt (TIPS) procedure
        • indication
          • refractory variceal bleeding
        • complication
          • hyperammonemia
  • Complications
    • Variceal bleeding
    • Hepatic encephalopathy
    • Hepatorenal syndrome

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(M2.OMB.4746) A 52-year-old man presents to the emergency department by ambulance for evaluation of hematemesis. His wife states that he began vomiting bright red blood this evening while eating dinner, and has produced about 5 cups total. He has a history of alcohol use disorder and has vomited small streaks of blood in the past, but has never undergone formal medical workup for it. On exam, he has bright red blood in his mouth and pharynx, and also displays a distended abdomen with a fluid wave, jaundice, scattered spider angiomas, and multiple ecchymoses. His temperature is 98.4°F (36.9°C), blood pressure is 98/68 mmHg, pulse is 125/min, and respirations are 22/min. A rapid point-of-care hemoglobin and platelet count is 8.8 g/dL and 80,000/mm^3, respectively. The patient is given 1L of normal saline. Which of the following is the most appropriate initial step in management?

QID: 216270

Balloon tamponade

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Ceftriaxone

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Nadolol

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Octreotide

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Platelet transfusion

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