• Dilated submucosal esophageal veins due to cirrhosal portal hypertension
    • are tributaries of the left gastric vein  
    • found in lower 1/3 of esophagus
    • associated with painless bleeding
  • Consider major risk factors and history to consider sources of bleed
    • NSAID use, alcohol use, liver disease / known varices, severe retching, prior abdominal surgery, trauma, coagulopathy, anticoagulation
  • Physical exam
    • vital signs with orthostatics
    • HEENT: epistaxis, telangiectasias, dried blood in oropharynx
    • abdominal exam: ascites, peritoneal signs, distension
    • rectal exam (black/tarry = melena; bright red blood = hematochezia), palpable masses, external anal findings (e.g. hemorrhoids, fissures)
  • Nasogastric tube
    • coagulopathy and varices are not contraindications for NG tube placement.
    • lack of blood in NG aspirate does not rule out upper GI bleed as it may have only sampled gastric content (bleed may be duodenal)
  • Endoscopy 
    • important for assessment and treatment
  • Resuscitation
    • IV crystalloids
    • RBC and fresh frozen plasma transfusions if indicated
  • Pharmacologic
    • proton pump inhibitors (can be discontinued if there is no ulcer)
    • β-blockers  
      • used in patients with proven variceal bleeds after the acute bleed has resolved and after octreotide use
      • nonspecific beta blockers (propranolol, nadolol) can be used as secondary prophylaxis against variceal re-bleeding
    • isosorbide mononitrate
      • venodilator; reduces portal pressure
    • ceftriaxone
      • reduces variceal re-bleeding, infection, and mortality in patients with cirrhosis with or without ascites
    • octreotide
      • acts as a somatostatin analogue (constricts splanchnic circulation)
  • Surgical
    • transjugular intrahepatic portasystemic stent (TIPS)
  • Massive hematemesis
    • results from venous rupture

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