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  • • Etiologies include:

    • -Cirrhosis

      -Congenital hepatic fibrotic disorders

      -Acute liver failure

      -Budd-Chiari syndrome

      -Heart failure

      -Congenital atresia

      -Portal or splanchnic vein thrombosis

    • 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

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Epidemiology

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  • • Most patients with history of cirrhosis

    • Presenting symptom of cirrhosis in many patients

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Symptoms and Signs

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  • • Hematemesis

    • Melena

    • Jaundice

    • Encephalopathy

    • Distended abdominal wall veins (caput medusa)

    • Ascites

    • Edema

    • Shock

    • Palmar erythema

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Laboratory Findings

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  • • Hyperbilirubinemia

    • Elevated international normalized ratio (INR)

    • Anemia

    • Azotemia

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Imaging Findings

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  • 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

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  • • 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)

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Rule Out

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  • • Other sources of upper GI bleeding using esophagogastroscopy

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  • • 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

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When to Admit

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  • • All patients with bleeding varices

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  • • Sclerotherapy or banding of varices

    • TIPS

    • Sengstaken-Blakemore tube placement

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Surgery

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  • • Liver transplantation

    • Surgical portosystemic shunt (TIPS vs total vs partial vs selective)

    • Gastric devascularization (Segura)

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Indications

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  • 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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Medications

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  • • β-Blockers

    • Nitrates

    • Vasopressin (during bleeding)

    • Octreotide (during bleeding)

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Treatment Monitoring

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  • • Repeat gastroesophagoscopy for suspicion of bleeding

    • Duplex US for suspicion of shunt thrombosis

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Complications

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  • • Encephalopathy ...

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