Updated: 9/3/2019

Esophageal Varices

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Snapshot
  • A 60-year-old man with a history of alcoholic cirrhosis presents to the emergency room after an episode of coffee-ground emesis. He had been drinking for the past few days and reports that he had not been eating properly. He is found to be fecal occult positive. On cutaneous exam, he has palmar erythema and scattered telangiectasias.
Introduction
  • Overview
    • esophageal varices result as a 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
Complications
  • Variceal bleeding
  • Hepatic encephalopathy
  • Hepatorenal syndrome

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Questions (3)
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(M1.GI.14.17) A 60-year-old male presents to your office for follow-up after an upper gastrointestinal (GI) endoscopy revealed the presence of esophageal varices. His medical history is significant for cirrhosis caused by heavy alcohol abuse for the past 20 years. He was instructed to follow-up with his primary care physician for management of his condition. Which of the following is the most appropriate next step for prevention of future variceal bleeding?

QID: 102596
1

Careful observation

9%

(17/198)

2

Octreotide

23%

(46/198)

3

Nadolol

32%

(63/198)

4

Isosorbide mononitrate

2%

(4/198)

5

Transjugular intrahepatic portosystemic shunt

31%

(61/198)

M 3 C

Select Answer to see Preferred Response

(M1.GI.14.15) A 57-year-old female with a past medical history of alcoholism presents to the emergency room vomiting bright red blood. She is accompanied by her partner, who reports that she had been complaining of black and tarry stools for the past several days. Vital signs are temperature 37 degrees celsius, heart rate 141 beats per minute, blood pressure 90/60, respiratory rate 20, and oxygen saturation 99% on room air. On physical examination, she has splenomegaly and a positive fluid wave. The remainder of her examination is within normal limits. The patient is stabilized with intravenous fluids, and her blood pressure improves. Subsequent emergent upper endoscopy reveals bleeding from the submucosal veins in the lower 1/3 of the esophagus, but no gastric bleed. In the endoscopy suite she also receives IV octreotide. After intervention and resolution of her acute bleed, which of the following pharmacologic agents is indicated?

QID: 104806
1

Phentolamine

11%

(13/118)

2

Prazosin

10%

(12/118)

3

Nifedipine

19%

(23/118)

4

Nadalol

47%

(56/118)

5

Doxazosin

4%

(5/118)

M 3 E

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