• GI bleeding:
  • 75% of time, painless hematemesis and/or melena
  • Occult bleeding with anemia 25%
• Signs of cirrhosis

Signs and Symptoms

History

• Generally a history of cirrhosis or liver disease
• Painless hematemesis or melena

• Possible hypotension/tachycardia
• Small, hard liver
• Splenomegaly
• Ascites
• Visible abdominal periumbilical collateral circulation (Caput medusae)
• Spider angiomata on upper chest/back
• Palmar erythema

Diagnostic Tests and Interpretation

Lab
Initial Labs

• Anemia related to blood loss
• Possibly abnormal liver function tests, thrombocytopenia, prolonged prothrombin time or low albumin-reflecting cirrhosis

• Barium swallow
  • Adequate for advanced varices, but is insensitive to small ones
  • Precludes possible urgent endoscopy
• Doppler sonography: Demonstrates patency, diameter, and flow in portal vein, and splenic vein, and large collaterals intra-abdominally
• MRI:
  • Demonstrates large vascular channels intra-abdominally, and in the mediastinum
  • Can demonstrate patency of the intrahepatic portal vein and splenic vein
• Venous phase celiac arteriography: Demonstrates portal vein and its collaterals, also can diagnose hepatic vein occlusion

• Esophagoscopy as part of esophagogastroduodenoscopy:
  • Can identify and treat varices that appear as protruding submucosal veins in the distal 3rd of the esophagus
  • Can identify actively bleeding varices as well as those with stigmata of recent hemorrhage
  • Can treat actively bleeding vessels with sclerotherapy or esophageal band ligation or can obliterate vessels to prevent rebleeding. Can also identify associated conditions, including gastric varices and portal hypertensive gastropathy.
• Endoscopic ultrasound is particularly sensitive to gastric varices.
• Portal pressure measurement
  • Radiologist introduces a catheter retrograde into the hepatic vein in a wedged position to occlude flow
  • The catheter is withdrawn to a free position and pressure again measured. The difference between wedged and free is the portal pressure. If <12 mm Hg, bleeding is less likely. Progressive increases above 12 correlate with the likelihood of hemorrhage.
  • This is sometimes used to monitor successful treatment with beta-adrenergic blocking agent though it is not widely available.

• Extensive collateral circulation in the mediastinum and in the abdomen in addition to large vessels in the submucosa of the esophagus
• When bleeding occurs, these large veins explode into the submucosa of esophagus and rupture into the lumen.

Differential Diagnosis

• Upper GI bleeding:
  • Pulmonary bleeding; hemoptysis
  • Peptic ulcer disease
  • Gastric or esophageal malignancy
  • Arteriovenous malformation (AVM)
  • Nosebleed
• Lower GI bleeding:
  • Hemorrhoids
  • Colonic neoplasia
  • Diverticulosis
  • AVMs