Gastroesophageal varices: Clinical sciences

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Introduction0:00–0:48

Gastroesophageal varices are abnormally enlarged veins in the distal esophagus and stomach. They arise when the veins that connect the portal circulation with the systemic circulation become dilated due to portal hypertension.
Now, when scar tissue in the liver or portal vein thrombosis cause portal vein hypertension, the blood starts flowing through smaller veins, like the ones in the distal esophagus or stomach, which are not designed to carry large volumes of blood.
This can result in complications such as bleeding, which is considered an emergency. Depending on the cause, varices can result from cirrhotic or non-cirrhotic portal hypertension.

ABCDE assessment and Unstable patients0:48–3:28

When assessing a patient with signs and symptoms suspective of gastroesophageal varices, you should first perform an ABCDE assessment to determine whether your patient is stable or unstable.
Now, if the patient is unstable, first initiate acute management to stabilize the airway, breathing, and circulation. This means that you might need to provide supplemental oxygen, or sometimes intubate the patient to protect the airway, establish IV access, and possibly perform gastric lavage to remove bloody stomach content.
Additionally, give fluid resuscitation to prevent death from hemorrhagic shock; if the patient doesn't stabilize with IV fluids, they may need an uncrossmatched blood transfusion.
Once these important steps are done, obtain a focused history and physical exam, as well as labs like CBC to assess the severity of blood loss, and PT, PTT, and INR to check for a possible coagulopathy that might have contributed to bleeding, which is common in patients with liver disease.
In addition, order blood typing and crossmatch in case the patient needs a blood transfusion. History usually reveals hematemesis, melena, or sometimes hematochezia.
The patient might also report lightheadedness. When it comes to the physical exam, you might notice that the patient is vomiting large amounts of bright red blood and clots.
Additionally, the exam might reveal black, tarry, or even frank bloody stool, altered mental status, and signs of hemodynamic instability, like tachycardia and hypotension.
Finally, labs might reveal low hemoglobin, or elevated PT, PTT, or INR, which points to coagulopathy. If based on history, physical exam, and labs, you suspect gastroesophageal varices, order an esophagogastroduodenoscopy, or EGD for short, to confirm the diagnosis.
If you see actively bleeding varices on EGD, you can diagnose gastroesophageal varices and move on to treatment. If not, you should consider an alternative diagnosis.
Alright, the treatment for varices involves endoscopic band ligation. Next, you should administer broad-spectrum antibiotics to reduce the risk of infection like bacteremia; and vasoconstrictors like octreotide to reduce the bleeding.
Next, monitor hemoglobin and hematocrit levels and correct any coagulopathy if found. Now that unstable patients are taken care of, let’s go back to the ABCDE assessment and talk about stable patients.

Stable patients3:28–4:01

If the patient is stable, your first step is to obtain a focused history and physical exam. Here is a high-yield fact!
Gastroesophageal varices are often asymptomatic until they bleed. So, you should look for signs and symptoms of portal hypertension, such as visible abdominal wall veins or an abdominal fluid wave from ascites.Alright, let’s start with cirrhotic portal hypertension.

Cirrhotic portal hypertension4:01–5:51

Patients with gastroesophageal varices caused by cirrhotic portal hypertension typically report symptoms of cirrhosis like jaundice, fatigue, and abdominal swelling; as well as symptoms of altered mental status such as confusion or disorientation.
They might also have a history of cirrhosis, alcohol use disorder, or viral hepatitis. When it comes to the physical exam, it might reveal signs of cirrhosis, like a fluid wave from ascites, caput medusae, palmar erythema, and asterixis.
Additionally, when palpating the abdomen, you might find a firm liver, and splenomegaly.Alright, if you see these signs and symptoms, order labs like CBC and CMP to assess liver function, as well as PT, PTT, and INR.
Labs might reveal anemia, thrombocytopenia, low albumin, and possibly elevated ALT, AST, and indirect bilirubin, as well as elevated PT, PTT, and INR.
These findings suggest cirrhosis, so you can proceed with imaging like ultrasound, CT, or MRI, and a possible biopsy to confirm the diagnosis.
If there is cirrhosis, imaging typically shows a small nodular liver, splenomegaly, and enlarged portal vein, while the biopsy can reveal fibrosis and nodularity.
This confirms the diagnosis of cirrhosis, so in this case we are talking about cirrhotic portal hypertension. The next step for these patients involves EGD to assess the size and condition of varices.Alright, let’s go back to the history and physical and talk about non-cirrhotic portal hypertension.

Non-cirrhotic portal hypertension5:51–6:34

In this case, history might reveal malignancy, vascular disease, systemic infiltrative disease, or a hypercoagulable state.
On the flip side, a physical exam might reveal splenomegaly. If you see these signs, order a doppler ultrasound to assess portal vein flow.
If you see portal vein compression or thrombosis on ultrasound, you can diagnose non-cirrhotic portal hypertension. Once again, you should order an EGD to assess the size and condition of varices.
Alright, let’s talk about EGD. First, if you don’t see any signs of varices, repeat EGD in 2 to 3 years.

EGD6:34–6:55

On the other hand, if you see varices on EGD, be sure to note their location and whether they are bleeding or not. First, let’s talk about non-bleeding varices.

Varices: No bleeding6:55–8:19

Now, if varices are not bleeding, you should determine their size. Small varices that are 5 millimeters or less in size don’t require any treatment.
However, you should repeat the EGD in 2-3 years to reassess them. On the flip side, medium and large varices usually require treatment.
Now, besides the difference in size, medium and large varices might have signs of increased bleeding risk called red signs.
These signs include red patches or strips and cherry red spots. For medium and large varices, you should start the patient on non-selective beta blockers like propranolol to decrease the risk of bleeding.
Additionally, you might need to consider endoscopic therapies like band ligation and sclerotherapy, or consult the interventional radiology team to perform a Transjugular intrahepatic portosystemic shunt, or TIPS for short.
During TIPS, the portal vein is connected directly to the hepatic vein, which allows the blood to bypass the liver, so the pressure in the portal vein decreases.
Another treatment option is portacaval shunt surgery, in which a connection between the portal vein and the inferior vena cava is made to bypass the liver.
Finally, don’t forget to treat the underlying cause of varices, which might mean you need to consider transplant referral, as that is the only way to treat cirrhosis.Okay, now that we are done with varices that don’t bleed, let’s switch gears and talk about the ones that do.

Varices: Active bleeding8:19–9:14

Sometimes, on EGD you might notice actively bleeding varices that haven’t become symptomatic yet. If this is the case, start the treatment right away.
First, administer broad-spectrum antibiotics and vasoconstrictors like octreotide. You might also need to provide vitamin K and consider blood transfusion.
Additionally, you will need to control the bleeding and this can be done with endoscopic therapies, such as band ligation or sclerotherapy.
You might also need to call an interventional radiology consultation for coiling, embolization, or TIPS; or portocaval shunt surgery.
As before, don’t forget to treat the underlying cause. Once the bleeding is stopped, you can repeat the EGD in 2 weeks to assess if the bleeding completely resolved, or if it persisted or recurred.

Review9:14–10:38

Alright, as a quick recap... Gastroesophageal varices can cause bleeding, which is considered an emergency.
Unstable patients require EGD to identify the varices. If found, they should be managed with endoscopic therapy, broad-spectrum antibiotics, vasoconstrictors, transfusion, hemoglobin and hematocrit monitoring, and correcting any underlying coagulopathy.When it comes to stable patients, they should be assessed with EGD as well.
Small non-bleeding varices don’t require treatment but should be reassessed in 2 to 3 years. On the other hand, medium and large varices require non-selective beta blockers to decrease the risk of bleeding, and possibly invasive management with endoscopic therapy, TIPS, or portocaval shunt surgery.
Don’t forget to treat the underlying cause. Now, if varices are bleeding, you should administer broad-spectrum antibiotics and vasoconstrictors; start vitamin K; and possibly transfuse blood products.
These patients might also need invasive management with endoscopic therapy, coiling, embolization, TIPS, or portocaval shunt surgery.
Again, don’t forget to treat the underlying cause, and reassess with EGD in 2 weeks.