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)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.GI.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?
Review Topic

QID: 102596
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1

Careful observation

10%

(14/137)

2

Octreotide

24%

(33/137)

3

Nadolol

26%

(35/137)

4

Isosorbide mononitrate

2%

(3/137)

5

Transjugular intrahepatic portosystemic shunt

36%

(50/137)

M1

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(M1.GI.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? Review Topic

QID: 104806
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1

Phentolamine

11%

(6/56)

2

Prazosin

11%

(6/56)

3

Nifedipine

29%

(16/56)

4

Nadalol

38%

(21/56)

5

Doxazosin

7%

(4/56)

M1

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