Gastroesophageal varices: Clinical sciences

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.

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. 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. 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.