His review of symptoms is significant for mild abdominal discomfort and ankle edema. He is married with grown up children and is still working in a local hardware store. He has a remote history of drug use and quit drinking over a year ago when he first developed ascites. Medications include diuretics and lactulose. His past medical history is unremarkable without evidence of diabetes, heart or lung disease, or prior surgeries.
His liver disease has been complicated by ascites and encephalopathy and he has small varices although no history of GI bleeding.
He has a history of cirrhosis secondary to hepatitis C and alcohol. Hence, it is important to document portal vein patency prior to EGD if possible since this will influence how aggressive you should be with endoscopic treatment.Ī 54-year-old man presents for liver transplant evaluation. If the portal vein is open, the patient should undergo transjugular intrahepatic portosystemic shunting (TIPS) which controls bleeding in the majority of cases. Band ligation of such large varices would be inadvisable but could be tried if the varices were smaller (which is a judgment call). Endoscopic treatment of isolated gastric varices is of limited benefit, although cyanoacrylate has shown some promise (but is not available in the United States). The patient has isolated gastric varices and several red spots are seen on the EGD image which are indicative of recent bleeding. Pharmacological therapy with intravenous octreotide should be standard in patients with suspected portal hypertensive bleeding and should be started prior to the EGD, and antibiotics have also been shown to reduce mortality in this situation. However, after adequate resuscitation, repeat EGD is required. The latter is important to document the patency of the portal vein. The initial work up should include an imaging study such as a CT scan or ultrasound scan (USS) (with Doppler).
The laboratory values suggest well-compensated disease but this does not exclude significant portal hypertension. The latter will include ulcer disease, malignancy, and a Dieulafoy lesion, while the former includes variceal bleeding (esophageal or gastric) and severe portal hypertensive gastropathy. The differential diagnosis is essentially all causes of GI bleeding, but these should be separated into portal hypertensive and non-portal hypertensive causes in a patient with known cirrhosis.
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