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