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
QUESTIONS 1 of 3 1 2 3 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 102596 Type & Select Correct Answer 1 Careful observation 8% (14/171) 2 Octreotide 25% (43/171) 3 Nadolol 30% (51/171) 4 Isosorbide mononitrate 2% (4/171) 5 Transjugular intrahepatic portosystemic shunt 33% (56/171) M 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (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? Tested Concept QID: 104806 Type & Select Correct Answer 1 Phentolamine 12% (11/91) 2 Prazosin 9% (8/91) 3 Nifedipine 19% (17/91) 4 Nadalol 52% (47/91) 5 Doxazosin 5% (5/91) M 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept
All Videos (1) Login to View Community Videos Login to View Community Videos Banding of bleeding esophageal varices Gastrointestinal - Esophageal Varices D 3/30/2013 84 views 5.0 (2)