Diagnosis: Esophageal Variceal Bleed
Case Summary:
Hematemesis has a broad differential including esophageal and gastric variceal bleed, peptic ulcer disease, Mallory Weiss tear and Dieulafoy lesions.
50% of patients with cirrhosis develop esophageal varices, 1/3 of whom develop hemorrhage. Child Pugh class B and C patients are at highest risk. Each bleeding event is associated with 15-20% mortality risk and it is therefore important to follow evidence-based guidelines for resuscitation and management of bleeding. This includes use of a restrictive transfusion strategy (Hb threshold 7.0g/dl), decreasing portal pressures with octreotide, clot stabilization with PPIs, and antibiotic prophylaxis, preferably with ceftriaxone.
Urgent endoscopy should be performed for variceal band ligation. Early TIPS placement has been shown to decrease mortality rate in select patients, however further trials are warranted. Given the risk of recurrent EV bleeding (22% recurrence rate), liver transplant is the best definitive treatment.
Case authored by: Jaclyn Chesner MD and Bhavana Bhagya Rao MD
References
- Garcia-Tsao G, Abraldes JG., Berzigotti A, Bosch J. Portal Hypertensive Bleeding in Cirrhosis: Risk Stratification, Diagnosis, and Management: 2016 Practice Guidance by the AASLD. Hepatology. 2017; 65(1): 310-335.
DOI 10.1002/hep.28906 - Villaneuva C, Colombo A. Bosch A., et al. Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. N Engl J Med. 2013; 368:11-21.
DOI: 10.1056/NEJMoa1211801 - Habib A, Sanyal AJ. Acute variceal hemorrhage. Gastrointest Endosc Clin N Am. 2007; 17(2):223-52.
DOI: 10.1016/j.giec.2007.03.005
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