- What is the diagnosis?
Large, dilated submucosal esophageal veins are present. These are varices. The abdomen demonstrates dilated superficial veins, a condition known as caput medusa.
- What causes this to happen?
The veins dilate as portal venous hypertension from cirrhosis of the liver in alcoholism leads to shunting of venous blood to collateral veins. These collateral veins then become dilated. Those dilated veins just under the esophageal mucosa can be eroded very easily, leading to extensive hemorrhage.
- What are therapeutic options?
Blood product therapy is often needed to stabilize the patient because of the marked blood loss. Endoscopy can be performed to help diagnose the cause of the bleeding. Via upper GI endoscopy, a sclerosant can be injected into the varices. Banding of the varices can be performed. A TIPS (transjugular intrahepatic portosystemic) shunt procedure (seen in image 7.6) can be done to reduce collateral venous pressure.
- What is the differential diagnosis of acute upper GI hemorrhage?
| Cause | % of Cases
| | Peptic ulcer disease | 40%
|
| Esophagitis | 10%
|
| Varices | 5%
|
| Mallory-Weiss tear | 5%
|
| Neoplasm | 5%
|
| Erosive disease | 5%
|
| Other identifiable cause | 5%
|
| No identifiable cause | 25%
|
- Is blood product therapy futile with massive GI bleeding?
The word 'futile' is derived from the ancient Greek word for a leaky bucket. The closest thing to that in medicine, literally, is someone who is bleeding out. Blood products represent a limited resource, and judgment is required in their use. Using more blood products for one patient means that fewer products are available for other patients. However, for an individual patient, this is a difficult decision. One must be cognizant of probable outcomes and be realistic.
