The most common presentation is hematemesis and there could also be melena. Other symptoms are abdominal pain, dysphagia, odynophagia, and other features of liver disease or underlying medical condition. They could also present in confusion secondary to hepatic encephalopathy. On physical examination, patient will be pale, hypotensive and could be in shock, with reduced urine output, and could be unconscious/subconscious. There would also be signs of liver disease and signs of overwhelming infection might also be seen.

• Sepsis

  Last Update: 2012-04-10 Usage Frequency: 3 Quality: Finnish Septinen sokki, aivokalvotulehdus, neutropeeninen sepsis, sepsis, Escherichia - sepsis, Clostridium difficile - sepsis, Enterobacter- bakteremia, subakuutti endokardiitti, bronkopneumonia, lobaaripneumonia [mymemory.translated.net]

  Even after the bleeding has been stopped, there can be serious complications, such as pneumonia, sepsis, liver failure, kidney failure, confusion, and coma. [webmd.com]

  Signs of sepsis may also commonly be present. Investigations Endoscopy is required at an early stage. [ 5, 6 ] FBC - haemoglobin may be low; MCV may be high, normal or low; platelets may also be low; WCC may be raised. Clotting including INR. [patient.info]

• Congestive Heart Failure

  A 51-year-old woman was admitted with intractable congestive heart failure and progressive anemia. She had undergone mitral valve replacement for mitral regurgitation at age 23 years. [ncbi.nlm.nih.gov]

  Register Esophageal Varices in the Absence of Cirrhosis: Incidence and Characteristics in Congestive Heart Failure and Neoplasm of the Liver - 24 Hours access EUR €36.00 GBP £28.00 USD $45.00 Rental This article is also available for rental through DeepDyve [academic.oup.com]

  Congestive heart failure, severe tricuspid regurgitation, and severe pulmonary hypertension (mean pulmonary pressures > 45 mm Hg) are therefore considered absolute contraindications to TIPS placement. 3,4 This is why echocardiography is recommended to [mdedge.com]

  The most common cause is liver damage (cirrhosis), but it can also be the result of severe congestive heart failure, a blood clot somewhere in the portal vein system (thrombosis or Budd-Chiari syndrome), inflammatory disease (sarcoidosis), or a parasitic [wikihow.com]

• Pneumonia

  The patient had an uneventful postoperative course without any complications such as anastomotic leakage or pneumonia. [ncbi.nlm.nih.gov]

  […] following terms: pneumonia, atypical pneumonia, bronchopneumonia, lobar pneumonia, bacterial pneumonia, fungal pneumonia, pneumonia influenza, and pneumococcal pneumonia. d The term herpes zoster is a grouping of the following terms: herpes zoster, oral [mymemory.translated.net]

  Pneumonia or bacterial peritonitis occurred in 11 percent of the patients in the sclerotherapy group and 2 percent of those in the ligation group. [nejm.org]

  Chronic obstruction shows the same syndrome but with a gradual development and a tendency to develop aspiration pneumonia. Palpating an esophageal obstruction in a cow. [medical-dictionary.thefreedictionary.com]

• Pleural Effusion

  Another advantage of TIPS is that it can help reduce the accumulation of fluid in the abdomen (ascites) or around the lungs (pleural effusions) in cirrhotic patients with fluid retention. [liver.ca]

  None of the patients developed deep ulcers, and there were no other complications such as pleural effusion, mediastinitis, or pneumonia during the study (Hepatology Research 2002;23:220–225). [gastrojournal.org]

  No No Yes Yes Complications Oesophageal strictures and ulcerations, pleural effusions and mediastinitis Complications are those associated with the endoscopic procedure Shunt insufficiency resulting in recurrent bleeds Major surgical procedure with associated [hepatitiscentral.com]

  effusion. [8, 15] Serious complications related to sclerotherapy have been reported in 15-20% of patients. [emedicine.medscape.com]

  Complications were defined as any untoward events (e.g., pneumonia, pleural effusion, bacterial peritonitis, and esophageal stricture or perforation) that required active treatment or prolonged hospitalization. [nejm.org]

• Hematemesis

  We herein report a case of a 50-year-old male with hematemesis due to the rupture from esophageal varices coexisting with multiple liver tumors metastasizing from sigmoid colon cancer. [ncbi.nlm.nih.gov]

  Also, assign code 578.0, Hematemesis, to identify the gastrointestinal bleeding. [aapc.com]

• Melena

  A young woman with a benign superior vena cava stenosis due to a tunneled internal jugular vein dialysis catheter presented with hematemesis and melena. [ncbi.nlm.nih.gov]

  Patients with acute bleeding[✎ edit | edit source] hematemesis (then melena); hypotension; other signs of hemorrhagic shock[1]. [wikilectures.eu]

  Objective: hematemsis-bloody vomitus, either bright red (indicate fresh blood) or "coffee ground" (indicate older blood that has been in the stomach long enough for gastric juices to act on it) melena (occult blood in stool) peripheral edema Idicators [quizlet.com]

  The most feared situation is a rupture of the varices that causes massive hemorrhage with blood vomiting and presence of black tarry blood in stool ( melena ). Without urgent medical assistance, the patient bleeds relatively quickly to death. [health-tutor.com]

• Black Stools

  Ballooning of blood vessels (veins) may cause vessels to rupture causing: vomiting of blood, tarry black stools. If large volume of blood is lost sign of shock will develop. [quizlet.com]

  A 58-year-old man with hepatitis B cirrhosis noticed black stools and underwent an endoscopy at a community hospital. The presence of esophageal varices (EVs) was confirmed, but the bleeding point was not found. [ncbi.nlm.nih.gov]

  The vessels may rupture, causing vomiting of blood and bloody stools or tarry black stools. If a large volume of blood is lost, signs of shock will develop. Any cause of chronic liver disease can cause bleeding varices. [anzgosa.org]

  Signs and Symptoms of Esophageal Varices Signs and Symptoms of Esophageal Varices may include the following: Lightheadedness Bloody stools Abdominal pain Hematemesis (blood in vomit) Shock or faintness due to blood loss Black stools If you or someone [eatingdisorderhope.com]

• Blood in Stool

  Veins experiences increase pressure & beome distended with blood, the vessels enlarge & varices develop. Ballooning of blood vessels (veins) may cause vessels to rupture causing: vomiting of blood, tarry black stools. [quizlet.com]

  The most feared situation is a rupture of the varices that causes massive hemorrhage with blood vomiting and presence of black tarry blood in stool ( melena ). Without urgent medical assistance, the patient bleeds relatively quickly to death. [health-tutor.com]

• Coffee Ground Emesis

  Patients with upper gastrointestinal (GI) bleeding—bleeding that originates in the esophagus and stomach, rather than in the intestines—can look for the following signs and symptoms: Vomiting bright red blood or coffee-ground emesis (very dark and granular [verywellhealth.com]

• Heart Failure

  A 51-year-old woman was admitted with intractable congestive heart failure and progressive anemia. She had undergone mitral valve replacement for mitral regurgitation at age 23 years. [ncbi.nlm.nih.gov]

  There may be more. hope this helps 7+ Year Member Joined: Feb 16, 2011 Messages: 555 Likes Received: 23 Status: Resident [Any Field] you can relate that to heart failure (if you have constritive pericarditis you have a diastolic disfunction, the ventricle [forums.studentdoctor.net]

  Register Esophageal Varices in the Absence of Cirrhosis: Incidence and Characteristics in Congestive Heart Failure and Neoplasm of the Liver - 24 Hours access EUR €36.00 GBP £28.00 USD $45.00 Rental This article is also available for rental through DeepDyve [academic.oup.com]

  Heart failure is a contraindication Pulmonary hypertension may follow TIPS placement because the shunt increases venous return to the heart. Additionally, systemic vascular resistance decreases in patients who have a shunt. [mdedge.com]

  The main causes of these conditions are: Cirrhosis of the liver Blood clots of the splenic, portal, or hepatic veins Abnormal connections between the arteries and veins in the liver or spleen Certain infections Severe heart failure Hodgkin lymphoma Sarcoidosis [winchesterhospital.org]

• Hypotension

  Hypotension occurred in two patients (1.1%, 2/182). No patient showed hypertension during the endoscopic therapy procedure. Bradycardia occurred in one patient (0.5%, 1/182), and hypoxia occurred in one patient (0.5%, 1/182). [ncbi.nlm.nih.gov]

  The concept of damage control resuscitation focuses on permissive hypotension, hemostatic resuscitation, and hemorrhage control to adequately treat the "lethal triad" of coagulopathy, acidosis, and hypothermia that occurs in trauma.[3] Hypotensive resuscitation [en.wikipedia.org]

  Patients with acute bleeding[✎ edit | edit source] hematemesis (then melena); hypotension; other signs of hemorrhagic shock[1]. [wikilectures.eu]

  ( Orthostatic hypotension ) - Rheumatic fever See also congenital ( Q20-Q28, 745-747 ) de:Ösophagusvarizen [wikidoc.org]

  On physical examination, patient will be pale, hypotensive and could be in shock, with reduced urine output, and could be unconscious/subconscious. There would also be signs of liver disease and signs of overwhelming infection might also be seen. [symptoma.com]

• Tachycardia

  If bleeding does occur the most common symptoms include: * Tarry black or bloody bowel motions * Vomiting up blood * Rapid breathing which tends to be shallow * Dizziness * Fast heart rate (tachycardia) * A fall in blood pressure * Clammy skin * General [alcoholrehab.com]

  Case presentation A 22 year-old woman presented with acute hematemesis, tachycardia, and hypotension after 3 days of melenic stools. [bmcgastroenterol.biomedcentral.com]

  Close attention should be paid to physiological responses to low-blood volume.[3] Tachycardia, tachypnea, and narrowing pulse pressure may be the initial signs. [en.wikipedia.org]

  Hypotension and tachycardia (ie shock). Reduced urine output. Melaena. Signs of chronic liver disease. Reduced Glasgow Coma Scale. Signs of sepsis may also commonly be present. [patient.info]

• Vein Disorder

  […] title=Category:Esophageal_varices&oldid=338271981 " Categorie : Diseases and disorders of the esophagus Portal hypertension Diseases and disorders of veins Categoria nascosta: Uses of Wikidata Infobox [commons.wikimedia.org]

• Dizziness

  Symptoms include severe bleeding in varices accompanied by vigorous hematemesis, leading to dizziness and loss of consciousness. Lesser bleeding from varices may cause the patient to swallow the blood instead of vomiting. [news-medical.net]

  If bleeding does occur the most common symptoms include: * Tarry black or bloody bowel motions * Vomiting up blood * Rapid breathing which tends to be shallow * Dizziness * Fast heart rate (tachycardia) * A fall in blood pressure * Clammy skin * General [alcoholrehab.com]

  Fatigue or dizziness should be reported as these could be signs of occult bleeding rather than a side effect of ß-blockers. [ncbi.nlm.nih.gov]

  Call 911 for any patient who is lethargic, confused, weak, dizzy, pale, cool to the touch, or sweating (diaphoretic). These patients are exhibiting signs of shock, which means the bleeding is severe and there is a high risk of death. [verywellhealth.com]

• Laboratory investigations should include complete blood count which may show low hemoglobin level and platelet count. Blood should also be taken for clotting profile including INR. Renal and liver function tests should also be done and blood should be taken for grouping and cross-matching as patient may require transfusion. 
• Esophagogastroduodenoscopy is the main investigation for diagnosis of this condition. It will show the location and size of the varices. If it is unavailable, a Doppler ultrasound can be done. Although it is a poor second choice, it can demonstrate varices when done by a skilled handler [7]. 
• Barium swallow and portal vein angiography and manometry should also be conducted. A chest X-ray should be done to exclude the possibility of aspiration and look for underlying chest infections. Ascitic tap for microscopy and culture is necessary if there are suspicions of bacterial peritonitis.

• Gastric Varices

  […] hypoalbuminemia (P CONCLUSIONS: The presence of gastric varices and red spots on esophageal varices were related to episodes of UGIB secondary to rupture of esophageal varices. [ncbi.nlm.nih.gov]

  […] in gastric variceal haemorrhage. [intechopen.com]

  From Wikidata Jump to navigation Jump to search Human disease Oesophageal varices Oesophageal varix Esophageal variceal ligation Variceal bleed Esophageal and gastric varices Acute variceal bleeding Oesophagus varices Bleeding esophageal varices Bleeding [wikidata.org]

• Hepatocellular Carcinoma

  Mean HVPG (both EH-HVPG and B-HVPG) was not significantly different among patients with different characteristics, including sex and comorbid factors, except for cases with hepatocellular carcinoma (B-HVPG, P = 0.01; EH-HVPG, P = 0.02). [ncbi.nlm.nih.gov]

• Pleural Effusion

  Another advantage of TIPS is that it can help reduce the accumulation of fluid in the abdomen (ascites) or around the lungs (pleural effusions) in cirrhotic patients with fluid retention. [liver.ca]

  None of the patients developed deep ulcers, and there were no other complications such as pleural effusion, mediastinitis, or pneumonia during the study (Hepatology Research 2002;23:220–225). [gastrojournal.org]

  No No Yes Yes Complications Oesophageal strictures and ulcerations, pleural effusions and mediastinitis Complications are those associated with the endoscopic procedure Shunt insufficiency resulting in recurrent bleeds Major surgical procedure with associated [hepatitiscentral.com]

  effusion. [8, 15] Serious complications related to sclerotherapy have been reported in 15-20% of patients. [emedicine.medscape.com]

  Complications were defined as any untoward events (e.g., pneumonia, pleural effusion, bacterial peritonitis, and esophageal stricture or perforation) that required active treatment or prolonged hospitalization. [nejm.org]

• Treatment can be medical and surgical. Medical management involves the use of splanchnic vasoconstrictors (like vasopressin, somatostatin and non-cardioselective beta blockers), venodilators (like nitrates) or a combination of both.
• Surgical management include endoscopic sclerotherapy and variceal band ligation. Ligation provides better control of hemorrhage and better outcomes but may be difficult to perform in a patient with active hemorrhage [8]. 
• If the above steps fail, a transjugular intrahepatic portosystemic shunt (TIPS) is used [9]. 
• A balloon tamponade could be used where TIPS is unavailable. It is very effective in stopping hemorrhage but carries a high risk of rebleeding and major complications when the balloon is removed.
• Patient may present needing emergency attention and emergency management to secure airway, breathing and proper circulation should be instituted immediately.

There is a recurrence rate of about 70% and up to 33% of a recurring hemorrhage will result in death. The highest risk of fatality is during the first few days after the bleeding episode and the risk begins to decline progressively after 6 weeks. There is about 65% mortality in patients with esophageal varices that could be attributed to associated disorders of the renal, cardiovascular and immune system [6].

Esophageal varices are caused by anything that can cause portal hypertension. Such cause could be prehepatic like portal vein thrombosis, portal vein obstruction and increased splenic flow. It could also be intrahepatic like liver cirrhosis, hepatitis, idiopathic portal hypertension and congenital hepatic fibrosis and posthepatic like Budd-Chiari syndrome, compression from a tumor and constrictive pericarditis.

Factors are also present which increase the risk for variceal bleeding and they include malnutrition, alcohol intake, decompensation of liver disease, increased intraabdominal pressure, non-steroidal anti-inflammatory drugs (NSAIDs), bacterial infection and circadian rhythms [2].

Esophageal varices account for up to 30% of all cases of upper gastrointestinal hemorrhage and they are seen in over 50% of patients with liver cirrhosis. Annually, up to 8% of patient with liver cirrhosis develop esophageal varices and the varices are large enough to have a risk of bleeding in about 3% of those that develop it. Up to 30% of patients with small varices will progressively develop large varices and are also therefore at a risk of bleeding. The mortality rate from esophageal variceal bleed is about 20% at 6 weeks although, in up to 40% of patients, bleeding stops spontaneously [3].

Portal hypertension develops in liver disease as a consequence of an increase in vascular resistance at either the prehepatic, intrahepatic or posthepatic levels. An increase in portal venous flow also contributes to the hypertension. Esophageal varices develop as the pressure in the portal vein continues to increase. The varices are small on the outset but as the hyperdynamic circulation increases, blood flow through the varices also increases and this raises the tension within the wall. When the expanding force exceeds the maximal wall elastic limit, there is rupture which will cause variceal hemorrhage. If the pressure in the portal vein does not reduce, then there is a risk of recurrence [4] [5].

There is no known method to prevent the formation of esophageal varices. Newly diagnosed patients with liver cirrhosis should be screened for varices. Varices can be treated with beta blockers and esophageal band ligation to significantly reduce the risk of bleeding [10].

Esophageal varices are porto-systemic collaterals. They are vascular channels that link the portal and systemic venous system and they form as a result of portal hypertension and are mostly seen in the lower one-third of the esophagus. The rupture of esophageal varices and subsequent bleeding is a major complication of portal hypertension. It is usually associated with a high mortality rate [1].

• Definition: Esophageal varices are dilated veins usually located at the lower end of the esophagus. They are usually as a result of liver disease which causes the pressure in the veins of the liver to increase. This condition could lead to death if these vessels rupture.
• Cause: The main causes are anything that will cause a liver disease. Some risk factors for formation of varices include chronic alcoholism, anything that will cause increased intraabdominal pressure, aspirin, NSAIDs, malnutrition and bacterial infections.
• Symptoms: The main symptoms is vomiting of pure blood and there could also be blood in the stool. Other symptoms are abdominal pain and pain on swallowing. There could also be symptoms arising due to the underlying liver disease like yellowness of the eyes and skin.
• Diagnosis: Diagnosis is usually confirmed by an endoscopic examination. This involves looking directly into the esophagus with a small camera. Ultrasound could be done if this is not available. Special X-rays and imaging of the blood vessels can also be done. Laboratory tests are done to check the blood level and cells, to check the kidney and liver function and also to prepare for possible blood transfusion.
• Treatment: Treatment involves the use of drugs to try and reduce the pressure in these veins. Surgery can also be done to either shrink the veins or tie them up to reduce the risk of bleeding.

1. Sanyal AJ, Bosch J, Blei A, Arroyo V. Portal hypertension and its complications. Gastroenterology. May 2008;134(6):1715-28
2. Sass DA, Chopra KB. Portal hypertension and variceal hemorrhage. Med Clin North Am. Jul 2009;93(4):837-53, vii-viii.
3. Gore RM, Livine MS, eds. Textbook of Gastrointestinal Radiology. 2nd ed. Philadelphia, Pa: WB Saunders Co; 2000:454-63, 2082
4. Cho KC, Patel YD, Wachsberg RH, Seeff J. Varices in portal hypertension: evaluation with CT.Radiographics. May 1995;15(3):609-22.
5. de Franchis R, Primignani M. Why do varices bleed?. Gastroenterol Clin North Am. Mar 1992;21(1):85-101.
6. Merkel C, Zoli M, Siringo S. Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) index. Am J Gastroenterol. Oct 2000;95(10):2915-20.
7. Liu CH, Hsu SJ, Liang CC, Tsai FC, Lin JW, Liu CJ, et al. Esophageal varices: noninvasive diagnosis with duplex Doppler US in patients with compensated cirrhosis. Radiology. Jul 2008;248(1):132-9
8. Garcia-Pagan JC, Bosch J. Endoscopic band ligation in the treatment of portal hypertension. Nat Clin Pract Gastroenterol Hepatol. Nov 2005;2(11):526-35.
9. Conn HO. Portal hypertension, varices, and transjugular intrahepatic portosystemic shunts. Clin Liver Dis. Feb 2000;4(1):133-50, vii.
10. Krige JE, Shaw JM, Bornman PC. The evolving role of endoscopic treatment for bleeding esophageal varices. World J Surg. 2005;29:966-73.