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Key Features

Essentials of Diagnosis

  • Develop secondary to portal hypertension

  • Found in 50% of patients with cirrhosis

  • Upper gastrointestinal bleeding develops in one-third

  • Diagnosis established by upper endoscopy

General Considerations

  • Esophageal varices are dilated submucosal veins that develop in patients with underlying portal hypertension and may result in serious upper gastrointestinal bleeding

  • Bleeding most commonly occurs in the distal 5 cm of the esophagus

  • Approximately 50% of patients with cirrhosis have esophageal varices

  • Bleeding from varices occurs in 30% of patients with esophageal varices

  • In the absence of any treatment, variceal bleeding spontaneously stops in about 50% of patients

  • Patients surviving this bleeding episode have a 60% chance of recurrent variceal bleeding, usually within the first 6 weeks

  • Factors that may portend an increased risk of bleeding include

    • Size of the varices

    • Presence at endoscopy of red wale markings on the varix

    • Severity of liver disease (as assessed by Child-Pugh score)

    • Active alcohol abuse—patients with cirrhosis who continue to drink have an extremely high risk of bleeding

Clinical Findings

Symptoms and Signs

  • Acute gastrointestinal hemorrhage, usually severe, resulting in hypovolemia, postural vital signs, or shock

Differential Diagnosis

  • Alcoholic gastritis

  • Mallory-Weiss syndrome

  • Portal hypertensive gastropathy

  • Peptic ulcer disease

  • Gastric or duodenal varices (rare)

  • Vascular ectasias (angiodysplasias), eg, idiopathic arteriovenous malformation, CREST syndrome, hereditary hemorrhagic telangiectasia

Diagnosis

Laboratory Tests

  • Complete blood count, platelet count, prothrombin time, INR

  • Serum liver enzymes

  • Creatinine, blood urea nitrogen

  • If bleeding, blood type and cross-match

Diagnostic Procedures

  • After the patient's hemodynamic status has been stabilized, emergent upper endoscopy is diagnostic

Treatment

Medications

  • Antibiotic prophylaxis reduces the risk of serious infection in hospitalized patients with cirrhosis and upper GI bleeding

  • Prophylactic administration of oral or intravenous antibiotics reduces the risk of serious infection to 10–20% as well as in-hospital mortality, especially in patients with Child-Pugh class C cirrhosis

    • Norfloxacin, 400 mg orally twice daily for 5–7 days

    • Ceftriaxone 1 g/d intravenously for 5–7 days

  • Vasoactive agents

    • Somatostatin, (250 mcg/h; not available in the United States) or octreotide, (50 mcg intravenous bolus followed by 50 mcg/h intravenously) infusion reduces splanchnic and hepatic blood flow and portal pressures

    • Terlipressin (1–2 mg intravenous every 4 hours; not available in the United States) causes significant reduction in portal and variceal pressures and, where available, may be preferred over octreotide

  • Combined vasoactive agents and endoscopic therapy (band ligation or sclerotherapy)

    • Superior to either modality alone in controlling acute bleeding and early rebleeding

    • May improve survival

  • Vitamin K, 10 mg subcutaneously

  • Lactulose 30 mL orally every 2–3 hours until evacuation occurs, then reduced to 15–45 mL/h every 8–12 hours as needed to promote 2–3 bowel movements daily for hepatic ...

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