questions 2

Esophageal Varices

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Topic updated on 02/26/16 7:45am

Introduction
  • Dilated submucosal esophageal veins due to cirrhosal portal hypertension
    • are tributaries of the left gastric vein  
    • found in lower 1/3 of esophagus
    • associated with painless bleeding
Evaluation
  • Consider major risk factors and history to consider sources of bleed
    • NSAID use, alcohol use, liver disease / known varices, severe retching, prior abdominal surgery, trauma, coagulopathy, anticoagulation
  • Physical exam
    • vital signs with orthostatics
    • HEENT: epistaxis, telangiectasias, dried blood in oropharynx
    • abdominal exam: ascites, peritoneal signs, distension
    • rectal exam (black/tarry = melena; bright red blood = hematochezia), palpable masses, external anal findings (e.g. hemorrhoids, fissures)
  • Nasogastric tube
    • coagulopathy and varices are not contraindications for NG tube placement.
    • lack of blood in NG aspirate does not rule out upper GI bleed as it may have only sampled gastric content (bleed may be duodenal)
  • Endoscopy 
    • important for assessment and treatment
Treatment
  • Resuscitation
    • IV crystalloids
    • RBC and fresh frozen plasma transfusions if indicated
  • Pharmacologic
    • proton pump inhibitors (can be discontinued if there is no ulcer)
    • β-blockers  
      • used in patients with proven variceal bleeds after the acute bleed has resolved and after octreotide use
      • nonspecific beta blockers (propranolol, nadolol) can be used as secondary prophylaxis against variceal re-bleeding
    • isosorbide mononitrate
      • venodilator; reduces portal pressure
    • ceftriaxone
      • reduces variceal re-bleeding, infection, and mortality in patients with cirrhosis with or without ascites
    • octreotide
      • acts as a somatostatin analogue (constricts splanchnic circulation)
  • Surgical
    • transjugular intrahepatic portasystemic stent (TIPS)
Complications
  • Massive hematemesis
    • results from venous rupture


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Qbank (2 Questions)

TAG
(M1.GI.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? Topic Review Topic

1. Phentolamine
2. Prazosin
3. Nifedipine
4. Nadalol
5. Doxazosin

PREFERRED RESPONSE ▶
TAG
(M1.GI.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?
Topic Review Topic

1. Careful observation
2. Octreotide
3. Nadolol
4. Isosorbide mononitrate
5. Transjugular intrahepatic portosystemic shunt

PREFERRED RESPONSE ▶

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