Updated: 9/10/2019

Esophageal/Gastric Varices

Topic
Review Topic
0
0
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
  • Epidemiology
    • incidence
      • 50% of patients with cirrhosis
    • risk factors
      • liver disease
        • cirrhosis
        • hepatitis C
        • alcohol use
      • NSAIDs
      • coagulopathy
        • splenic venous thrombosis
  • 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
  • Associated conditions
    • medical conditions and comorbidities
      • hepatic encephalopathy
      • ascites
      • bacterial peritonitis
      • primary biliary cirrhosis
      • Budd-Chiari syndrome
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
Studies
  • Serum labs
    • hemoglobin and hematocrit
    • platelet count
  • Invasive studies
    • esophagogastroduodenoscopy (EGD)
      • indications
        • all patients with GI bleed
        • diagnostic and can be therapeutic
      • findings
        • abnormal venous dilation
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
 

Please rate topic.

Average 5.0 of 1 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Topic COMMENTS (0)
Private Note