Eso Varices/Mallory Weiss

Question 1

Answer 1

Question 2

Portal Hypertension

general and common causes

caput medusae

Answer 2

An increase in the pressure within theportalvein
Common causes:
Cirrhosis due to chronic viral hepatitis C
Alcohol-induced liver disease

Question 3

Portal Hypertension

Clin man

Answer 3

Manifestations:
Esophageal varices
Caput medusae
Hypersplenism = over active spleen
Anemia
Neutropenia
Thrombocytopenia
Marked ascites
Hemorrhoids

Question 4

Portal HTN

Question 5

Portal HTN

Varix
Most common sites

Answer 5

Abnormally dilated vessel with a tortuous course
Usually occurs in the venous system, but may also occur in arterial or lymphatic vessels

Most common sites for varix formation:
Distal esophagus
Proximal stomach
Umbilicus
Rectum
Retroperitoneum

Question 6

Esophageal varices

general

Answer 6

Dilated submucosal veins in the distal esophagus connecting to the portal and systemic circulation
Most dangerous varices due to the risk of rupture → massive upper gastrointestinal bleeding
PAINLESS bleeding

Question 7

Esophageal varices

Risk factors for bleeding

Answer 7

Risk factors for bleeding:
Size of the varices
Presence of red whale markings (longitudinal dilated venules on the varix surface)
Severity of liver disease
Active alcohol abuse

Question 8

Variceal Bleeding

S/Sx of shock

Answer 8

Painless, upper GI bleeding
Acute, subacute, or chronic
Site of bleeding:
Distal esophagus – most often
Gastric fundus – less often

Acute massive bleed → shock
Systolic BP < 100 mm Hg
Pulse rate > 100 bpm, weak
Pale
Diaphoretic
Restless
Thirsty

Question 9

Esophageal varices bleeding

Diagnostics

Answer 9

Endoscopy
Test of choice for esophageal and gastric varices

Evaluation for coagulopathy
High association of varices and hepatic disease
PT/INR and PTT

Additional tests
CBC – anemia and thrombocytopenia
Liver tests – AST, ALT, Alkaline phosphatase, bilirubin

Question 10

esophageal varicose bleed

non pharm Tx

Answer 10

40% of variceal bleeds stop spontaneously
Bleeding varices - EMERGENCY

Airway management - Intubation
2 large-bore IVs
Fluid resuscitation
Blood transfusion
Type and cross-match 6 units of packed red blood cells
Correction of coagulopathy
1-2 units of fresh frozen plasma
Platelet transfusion (>50,000 mcL)

Question 11

esophageal varicose bleed

Pharm Tx and intervention

Answer 11

Antibiotics
3rd generation cephalosporins (Rocephin) IV to prevent bacteremia and sepsis

IV octreotide
Synthetic analog of somatostatin that reduces portal pressure

Endoscopic banding or sclerotherapy
Performed when the patient is hemodynamically stable

Question 12

Esophageal varicosity

prognosis
Chronic maintenance

Answer 12

Mortality depends primarily on the severity of the associated liver disease
20% mortality at 6 weeks
Recurrence rate of variceal bleeding is 50-75% within 1-2 years
β-blockers to ↓ recurrent bleeding- for chronic maintenance not acute Tx

Question 13

Mallory-Weiss Syndrome

general

Answer 13

Syndrome characterized by esophageal bleeding caused by a longitudinal laceration(s) at or near the gastroesophageal junction as a result of vomiting or retching
Repeated episodes (typical presentation)
Single episode
3x more common in men
Accounts for 5-10% of upper gastrointestinal bleeding

Superficial bleeds

Question 14

Mallory Weiss Syndrom

Patho

Answer 14

Pathogenesis:
Rapid ↑ in intraabdominal pressure and intragastric pressure
This pressure overcomes the lower esophageal sphincter pressure so the gastric contents are released into theesophagus
Normal autonomic reflexes cause theupper esophageal sphincter (UES) to relax → vomiting

Question 15

Mallory Weiss

RF

Answer 15

Alcohol use disorder
Seen in 40-80% of patients; may coexist with esophageal varices

Events that create a sudden rise in thepressure gradient across thegastroesophageal junction:
Forceful or recurrent retching
Vomiting
Violent coughingspasms
Blunt abdominal trauma

Question 16

Mallory Weiss

Clin man

Answer 16

Acute onset hematemesis
Presenting symptom in all patients
Variable amount
Streaks of blood → copious amount of fresh red blood
Severe bleeding
Shock (20% of patients)
Postural hypotension (45% of patients)
Normally preceded by one or more episodes of non-bloody emesis, retching, or coughing
Epigastric or back pain
Melena
Seen later in a patient Dx with a tear
May be light-headedness, dizziness, syncopal
Secondary to dehydration from underlying vomiting

typically bright red

Question 17

mallory weiss

Dx

Answer 17

Clinical suspicion with a history of hematemesis occurring after episode(s) of non-bloody vomiting

Esophagogastroduodenoscopy (EGD) Diagnostic study of choice for esophageal tears

Allows for visual inspection of the esophagus, stomach, and duodenum
Minimal bleeding and the patient is stable, EGD may be deferred, but the patient should be referred to GI
Severe bleeding with hemodynamic instability – stability must be obtained prior to performing the endoscopy
After 96 hours, most tears are well-healed and difficult to visualize

only do EGD on STABLE pt

Question 18

mallory weiss tear

Predictive Factors for Recurrent Bleeding

Answer 18

Initial presentation of shock
History of liver cirrhosis
Decreased hemoglobin requiring a blood transfusion
Low platelet count
Active bleeding noted at the time of endoscopy

Question 19

mallory weiss

Question 20

mallory weiss

non pharm Tx

Answer 20

Most episodes of bleeding stop spontaneously

Severe bleeding (10% of patients)
Close monitoring of vital signs
Place 2 large-bore IVs
Fluid resuscitation
Transfusion of PRBCs, if needed

Question 21

mallory weiss

pharm Tx

Answer 21

Pharmacotherapy
IV proton pump inhibitor (PPI) - used for acidsuppression

Question 22

mallory weiss

Labs

Answer 22

Labs
CBC and coagulation assessment (PT/INR, PTT)
Initially NPO; bleeding resolved → clear liquids

Question 23

mallory weiss

Endoscopic hemostasis

Answer 23

Used for patients who are hemodynamically unstable
Dilute epinephrine injections made 3-5 mm apart circumferentially around the site of bleeding
Electrocautery
Esophageal clips
Band ligation

Question 24

mallory weiss

Tx for difficult to treat tears

Answer 24

Arteriography with embolization

Surgical repair – rarely needed

Question 25

# Esophageal Perforation general

Answer 25

Spontaneous transmural perforation of the esophagus exposing the mediastinum to GI contents Iatrogenic perforation (85-90%) Endoscopic procedures or other instrumentation Penetrating injuries (gunshot wound > blunt injuries Foreign body ingestion Spontaneous perforation/rupture (**Boerhaave syndrome**) Most lethal perforation of the GI tract Mortality 30% → subsequent infection

Question 26

# esophageal perf Best outcomes result from

Answer 26

early diagnosis and definite surgical management within 12 hours of rupture

Question 27

# esophageal perf patho

Answer 27

Depends on the underlying cause Boerhaave syndrome: Sudden increase in intraluminal pressure in the esophagus, coupled with negative intrathoracic pressure, can lead to rupture Most common site of rupture is the lower posterolateral third of the esophagus

Question 28

# esophageal perf

Answer 28

-Vomiting -Severe retrosternal chest pain or epigastric pain -Subcutaneous emphysema (SCE) Occurs when gas or air (generally from the chest cavity) travels under the skin Usually occurs on the chest, neck, and face

Question 29

# esophageal perf other Sx aside from Macklers

Answer 29

Hematemesis: if present, diagnosis is often mistaken for Mallory-Weiss tear Chest pain Dysphagia Fever Shock

Question 30

# esophageal perf Imaging

Answer 30

Chest x-ray Suggests the diagnosis Pneumomediastinum Subcutaneous emphysema Contrast esophagography (Gastrograffin) **Confirms the diagnosis** Contrast leakage from the esophagus to the mediastinum Length 0f the perforation and its location CT scan of the chest Performed when: Chest x-ray or esophagography is inconclusive Patient is unstable

Question 31

# esophageal perf ABCDE survey

Answer 31

Airway: Ensure the patency of the airway Breathing: Ensure proper ventilation is occurring Circulation: Measure blood pressure and pulse, and administer IV fluids Disability: Perform basic neurologic examination Exposure: Search for injuries

Question 32

# esophageal perf Tx pharm and nonpahrm

Answer 32

ABCDE survey Close monitoring of vital signs Intravenous volume resuscitation NPO IV proton pump inhibitor (PPI) Administration of broad-spectrum antibiotics Prompt endoscopic stenting and/or surgical intervention

Question 33