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 login to view 3 more bullets NSAIDs coagulopathy login to view 1 more bullet Pathogenesis mechanism varices often develop in patients with portal hypertension varices offer a channel that diverts pressure from portal circulation to systemic circulation login to view 2 more bullets 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 login to view 4 more bullets Physical exam inspection signs of liver disease login to view 6 more bullets Studies Serum labs hemoglobin and hematocrit platelet count Invasive studies esophagogastroduodenoscopy (EGD) indications login to view 2 more bullets findings login to view 1 more bullet Differential Peptic ulcer disease key distinguishing factor EGD shows ulcers rather than abnormal venous dilation Treatment Medical resuscitation indication login to view 1 more bullet modalities login to view 2 more bullets somatostatin analogs indication login to view 1 more bullet drugs login to view 2 more bullets antibiotic prophylaxis indications login to view 2 more bullets drugs login to view 2 more bullets beta-blockers indications login to view 3 more bullets isosorbide mononitrate indications login to view 3 more bullets Surgical EGD indications login to view 2 more bullets modalities login to view 2 more bullets transjugular intrahepatic porto-caval shunt (TIPS) procedure indication login to view 1 more bullet Complications Variceal bleeding Hepatic encephalopathy Hepatorenal syndrome