• Etiologies include:
• Bleeding gastroesophageal varices most important complication
• 30% bleed
• 50% mortality for those who bleed
• 30% re-bleed in 6 weeks
• 70% re-bleed in 1 year
• Bleeding most commonly from esophageal varices
• 10-15% have associated gastric varices
• Presence of varices related to degree of liver dysfunction
• Portal vein-hepatic vein gradient invariably > 12 mm Hg
• CT scan: Dilated venous collaterals, possible venous thrombosis (hepatic, portal, superior mesenteric vein, splenic, etc.)
• US: Dilated portal vein, possible thrombosis of portal vein or hepatic veins
• Mesenteric venography: Dilated collaterals, thrombi, or blush from bleeding
• Hepato-portal venography: Wedge pressure generally > 12 mm Hg in presence of varices
• Esophagogastroscopy for diagnosis of varices and possible sclerotherapy
• Presence of thrombi
• Childs classification or Model of End-Stage Liver Disease (MELD) to determine transjugular intrahepatic portosystemic shunt (TIPS) vs surgical shunt
• Mesenteric venography if diagnoses other than cirrhosis being considered (eg, Budd-Chiari syndrome or portal vein thrombosis)
• ABCs if patient has upper GI bleeding
• Assessment of MELD or Child class
• Assessment of underlying etiology
• Early gastroesophagoscopy for banding or sclerotherapy
• Octreotide to control bleeding
• Blood products as necessary
• Invasive monitoring as necessary
• Sengstaken-Blakemore tube if necessary
• Portal venography if diagnosis in doubt or patient is a candidate for surgical shunt
• Liver transplantation: Availability of donor, no medical comorbidities, not currently drinking alcohol
• Surgical shunt: Childs A failed endoscopic therapy elective (selective) or emergent (partial)
• Gastric devascularization: Gastric varices and failed endoscopic therapy
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