Esophageal varices are swollen veins in the lower esophagus caused by high pressure in the portal vein, usually from cirrhosis. When they rupture they can bleed massively, so this is a medical emergency with high risk of death.
Key symptoms
- Vomiting large amounts of bright red blood or coffee-ground material
- Black, tarry stools
- Dizziness, fainting or weakness
- Known cirrhosis or heavy alcohol use
What you find on exam
- Fast heart rate and low blood pressure
- Pale, cool and clammy skin
- Signs of cirrhosis: jaundice, ascites, spider angiomas
- Level of consciousness and airway protection
Tests
- Blood count, type and crossmatch
- INR, platelets, liver tests and kidney function
- Urgent upper endoscopy within 12 hours
- Lactate and ongoing monitoring of vital signs
Treatment basics
- Two large-bore IVs, airway protection if needed, cautious transfusion to a hemoglobin of about 7
- IV octreotide to lower portal pressure
- IV antibiotics such as ceftriaxone for all patients with cirrhosis
- Endoscopic band ligation; TIPS if bleeding continues or returns
Red flags
- Ongoing vomiting of blood despite treatment
- Shock or decreased level of consciousness
- Airway at risk from blood or confusion
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.