Hepatic portal vein

Illustration (Anatomy recall)

Risk factors for upper GI bleeding
* Bleeding diathesis
* Peptic ulcer disease
* Use of alcohol or (NSAIDs)
* Documented cirrhosis
* Documented episodes of GI tract bleeding
* History of recent forceful retching or emesis
 Esophageal Varices
Physical
► Pallor may suggest active internal bleeding

► Low blood pressure and increased pulse rate

may suggest blood loss

► Parotid enlargement may be related to:

alcohol abuse and/or
malnutrition
Physical
► Cyanosis of the:
tongue
lips and
peripheries
may be due to low oxygen saturation (hypoxia)

► Patients may experience:

dyspnea and
tachypnea
Physical

► A hyperdynamic circulation with flow murmur

over the pericardium may be present

► Jaundice may be present because of impairment of

liver function
 Esophageal Varices
Physical
► Look for telangiectasis of the:
skin
lips and
digits

►Gynecomastia in males results from failure of the liver

to metabolize estrogen, resulting in a sex hormone
imbalance
 Esophageal Varices

Physical
► Fetor hepaticus occurs in portosystemic
encephalopathy of any cause (e.g.: cirrhosis)

► Palmar erythema and

Leuconychia
may be present in patients with cirrhosis
 Esophageal Varices
Physical
►Ascites, abdominal distention due to accumulation of fluid,
may be present

► Ascites may be associated with:

peripheral edema and
may involve the:
* abdominal wall and
* genitalia
 Esophageal Varices
Physical
► Numerous dilated veins radiating out of the umbilicus may be observed

► The liver may be small

► Splenomegaly occurs in portal hypertension

 Esophageal Varices

Physical
Testicular atrophy
is common in males with cirrhosis

Venous hums
may be present as a result of rapid turbulent flow in
collateral veins
 Esophageal Varices

Physical
During the rectal examination, obtain a stool sample
for visual inspection

A black, soft, tarry stool on the gloved examining

finger
suggests upper GI bleeding
 Esophageal Varices
Causes
Diseases interfering with portal blood flow can result in:
* portal hypertension and
* the formation of esophageal varices

Causes of portal hypertension usually are classified

as:
prehepatic
intrahepatic and
posthepatic
 Esophageal Varices

Causes
Prehepatic

Splenic vein thrombosis

Portal vein thrombosis

Extrinsic compression of the portal vein

Causes
Intrahepatic
Congenital hepatic fibrosis
Hepatic peliosis
Idiopathic portal hypertension
Sclerosing cholangitis
Tuberculosis
Schistosomiasis
Primary biliary cirrhosis
Alcoholic cirrhosis
Hepatitis B virus–related and
hepatitis C virus–related cirrhosis
Causes
Intrahepatic
Hepatitis B virus–related and
hepatitis C virus–related cirrhosis
Wilson disease
Hemachromatosis
Alpha-1 antitrypsin deficiency
Chronic active hepatitis
Fulminant hepatitis
 Esophageal Varices

Causes
Posthepatic
Budd-Chiari syndrome
Thrombosis of the inferior vena cava
Constrictive pericarditis
Venoocclusive disease of the liver
 Esophageal Varices
• Differentials Diagnosis

• Budd-Chiari Syndrome Cirrhosis

• Duodenal Ulcers Gastric Cancer

• Gastric Ulcers Mallory-Weiss Tear

• Portal Hypertension Portal Vein Obstruction

• Schistosomiasis Wilson Disease

 Esophageal Varices
Workup
Lab Studies
Complete blood count:
Results may show:
anemia
leucopenia and
thrombocytopenia in patients with cirrhosis

The hematocrit value may be low in patients with

upper abdominal bleeding
 Esophageal Varices

Type and
crossmatch blood
and order 6 units of packed red blood cells

Prothrombin time:
Because the coagulation factors involved in this test
are synthesized by the liver, impairment of the liver
function may result in a prolonged prothrombin
time
 Esophageal Varices

Liver function tests:

A mild elevation of the plasma activity of:

aspartate aminotransferase (AST) and

alanine aminotransferase (ALT)

may occur in cirrhosis, although activity may be
normal
 Esophageal Varices
blood urea and
creatinine levels
may be elevated in patients with esophageal
bleeding

►Cirrhosis, ► ascites, ► and blood loss

may contribute to changes in the serum
electrolytes of these patients
 Esophageal Varices

► Arterial blood gas and

pH measurements

► Hepatic serology helps in the assessment of the

cause of cirrhosis
 Esophageal Varices

Imaging Studies
Ultrasound of the upper abdomen may be indicated,
specially if:
* biliary obstruction or
* liver cancer is suspected
 Esophageal Varices

Procedures
Endoscopy is required at an early stage to
formulate the management plan

If active variceal bleeding or an adherent clot is

observed ► variceal hemorrhage can be
diagnosed confidently
 Esophageal Varices

Endoscopy
The presence of variceal red color signs

e.g.
cherry red spots
red whale markings,
blue varices
►indicates an increased risk of further bleeding
 Esophageal Varices
1) Medical Care
A) Esophageal varices with no history of bleeding
Patients with:
* esophageal varices and no
* previous history of variceal hemorrhage
should be treated with:
nonselective beta-adrenergic blockers
e.g.: propranolol
nadolol
timolol
 Esophageal Varices
1) Medical Care
provided that the use of beta-blockers is not contraindicated
e.g.:
* insulin-dependent diabetes mellitus
* severe chronic obstructive lung disease
* congestive heart failure
 Esophageal Varices
1) Medical Care
If contraindications to using beta-blockers exist, long-acting nitrates
e.g.: isosorbide 5-mononitrate
are alternatives

Remember
Treatment with beta-blockers should be continued indefinitely
 Esophageal Varices
1) Medical Care
B) Bleeding esophageal varices
Assess the:
rate and
volume of bleeding

Check:
blood pressure and
pulse
with the patient in the supine position and
with the patient in a sitting position
1) Medical Care
B) Bleeding esophageal varices
Gain: venous access and
obtain blood
for immediate hematocrit measurement
Obtain a: type and
cross-match
Measure the: platelet count and
prothrombin time
Send blood for: renal and
liver function tests and
measure serum electrolytes
1) Medical Care
C) Emergency treatment
Promptly: resuscitate and
restore the circulating blood volume
of patients with suspected:
cirrhosis and
variceal hemorrhage

Establish intravenous access for blood transfusion

1) Medical Care
C) Emergency treatment
While the blood is being cross-matched, start:
* rapid infusion of 5% dextrose and
* colloid solution
until the blood pressure is restored and urine output
is adequate

Establish airway protection in patients with massive

upper GI tract bleeding, especially if the patient is
not fully conscious
1) Medical Care
C) Emergency treatment
If indicated, correct clotting factor deficiencies with:
fresh frozen plasma
fresh blood and
vitamin K-1
Insert a nasogastric tube to assess the severity of
the:
bleeding and
to lavage gastric contents
before performing endoscopy
 Esophageal Varices

1) Medical Care
Endoscopic therapy probably has replaced
balloon tamponade as the initial therapy for variceal
bleeding

Balloon tamponade is now rarely necessary

 Esophageal Varices
1) Medical Care
Endoscopic therapy
1) Endoscopic sclerotherapy
* Is successful in controlling acute esophageal
variceal bleeding in up to 90% of patients

* Hemorrhagic control should be obtained with 1-2

sessions

* Patients continuing to bleed after 2 sessions should

be considered for alternative methods to control
their bleeding
 Esophageal Varices

1) Medical Care
Endoscopic therapy
Complications of sclerotherapy may include:
mucosal ulceration
bleeding
esophageal perforation
mediastinitis and
pulmonary complications
Long-term complications, such as:
esophageal stricture formation may also occur
 Esophageal Varices

1) Medical Care
Endoscopic therapy
2) Endoscopic variceal ligation (banding)
The esophageal mucosa and the submucosa
containing varices are ensnared

causing subsequent strangulation, sloughing,

and eventual fibrosis resulting in obliteration
of the varices
 Esophageal Varices

2) Surgical Care
Surgical care includes:

(1) decompressive shunts

(2) devascularization procedures and

(3) liver transplantation

Complications
Variceal hemorrhage is the most common
complication associated with portal hypertension
 Complications

► Other complications include:

hepatic encephalopathy
bronchial aspiration
renal failure
systemic infections
ascites
gastric varices and
hepatorenal syndrome
Thanks