University of St.

La Salle
College of Medicine
Internal Medicine | Case 1

Alvarez, Lothel; Amihan, Alyssa Marie; Aristosa, Ariane; Caram, Miguel; Asparo, Daniela; Kraft,
Rafaella Beatriz; Dalipe, Joshua; Ledesma, Jose Luis III; Decena, Andrea; Montalbo, Mark Benedict;
Ellaga, Czarina; Ramirez, Celin Jannica; Jose, Terence; Reyes, Ralph Lester; Sato, Koki; Ruiz, Mary
Grace; Uy, Ianeil Ritch; Tupas, Kharmyne Chelsea
____________________________________________________________________________________

Case 1:
C. L. , a 55 year old male, from Bacolod City, known with hypertensive cardiovascular disease
on Clopidogrel and Amlodipine therapy, and a chronic alcoholic for 20 years, consuming an
estimate of 2 bottles of Vodka and 7 bottles of Beer 3x a week, came in to RMC for
hematemesis and hematochezia of 2 days duration. Patient vomited 6 cups of bloody fluids on
the way to the hospital.

History further revealed that the patient had dysphagia for 2 months and weight loss of 10%
despite good appetite.

Patient came in restless and afebrile with vital signs of 80 palpatory and heart rate of 120 bpm.
Initial blood pressure at home was 130/60 mm Hg.

On physical examination:
+ pallor
Prominent veins on the abdomen and around the umbilicus
Abdomen was distended, soft, hypoactive bowel sounds, + epigastric tenderness, nonpalpable
liver, + obliteration of Traube's Space, + flapping tremors

Rectal exam: fresh blood on examining finger

Impression:

Upper GI Bleeding; Esophageal Varices secondary to Chronic Liver Disease

Initial treatment and laboratory work ups for the patient whilst in the emergency room:

Intravenous (IV) access, hemodynamic resuscitation

Monitor Mental Status
IV octreotide to lower portal venous pressure as adjuvant to endoscopic management.
IV bolus of 50 micrograms followed by a drip of 50 micrograms/hr.
Erythromycin 250 mg IV 30 to 120 minutes before endoscopy

Laboratories:
● CBC (monitor anemia, infections, general surveillance)
 ● BUN ( kidney function)
● Creatinine (kidney function)
● Electrolytes (monitor fluid balance)
● Urinalysis (monitor urine for renal calculi, urine crystals and hematuria)
● Fecalysis (determinant of GI function)
● Lipid Profile (monitor cardiac health, predisposing factors; clopidogrel maintenance)
● PT/APTT (liver function and coagulative disorders)
● Arterial Blood Gas (monitor ph balance)
● AST, ALT, GGT, Total Bilirubin, Direct Bilirubin, Indirect Bilirubin, Ammonia (liver tests)
Albumin (kidney, liver and vascular function)

Imaging: Esophagogastroduodenoscopy

● To identify actively bleeding varices as well as large varices and stigmata of recent
bleeding
● To treat bleeding with esophageal band ligation (preferred to sclerotherapy); prevent
rebleeding; detect gastric varices, portal hypertensive gastropathy; diagnose alternative
bleeding sites
● To identify and treat non-bleeding varices

3 Clinical Differential Diagnoses:

Salient features:
Chronic alcoholic
Hypertension
Anorexia
hematemesis
Hematochezia
Caput-medusae
+pallor
+ obliteration of Traube's Space/Splenomegaly
+ flapping tremors/asterixis

Mallory-Weiss Erosive Gastritis Portal Hypertensve

Syndrome Gastropathy

Most Likely Chronic alcoholic Hematemesis Hematemesis

Hypertension Chronic alcoholic Hematochezia
Hematemesis Hematochezia Hypertensive
+ pallor cardiovascular disease
Chronic Alcoholic

Least Likely Hematochezia Loss of appetite Dysphagia

(-) abdominal/chest pain No NSAIDs use (-)Diarrhea
(-) burning feeling and (-) Nausea
nausea Mild bleeding
What are the 3 possible endoscopic lesions that you can see on endoscopy?

In order to diagnose gastroesophageal varices, the gold standard approach is

esophagogastroduodenoscopy (EGD) (GOVs). Small (5 mm) and big varices (> 5 mm) GOVs
are categorized based on the endoscopic examination.

MODIFIED PAQUET CLASSIFICATION:

1. Grade I - varices extending just above the mucosal level and compression with air
insufflation.
2. Grade II - varices projecting by one-third of the luminal diameter that cannot be
compressed with air insufflation.
3. Grade III - varices projecting up to 50% of the luminal diameter and in contact with each
other.

Give the corresponding therapeutic endoscopy interventions based on your answers:

Esophageal Varices - Endoscopic variceal ligation(EVL), endoscopic variceal band

ligation, endoscopic variceal sclerotherapy, stent placement and balloon tamponade with a
Sengstaken-Blakemore tube.

What is the diagnostic approach of choice endoscopically?

In cases involving the need to examine the upper gastrointestinal mucosa, upper
endoscopy (or esophagogastroduodenoscopy) is the gold standard for diagnosis. This method
is both diagnostic and therapeutic.
References:

● https://www.researchgate.net/figure/Endoscopic-esophageal-varices-evaluation-adapted-
from-Paquet-and-Palmer-and-Brick_fig1_326632875
● https://www.ncbi.nlm.nih.gov/books/NBK448078/
● Harrison’s Principles of Internal Medicine 21st Edition
● Schwartz’s Principles of Surgery 11th Edition