gastrointestinal emergencies evidence based answers to key clinical questions end stage liver disease and variceal bleeding graham
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End-Stage Liver Disease and Variceal
Bleeding 18
Autumn Graham and Andrew C. Meltzer
hen Should I Suspect Esophagogastric
W
Pearls and Pitfalls Varices in a Patient with a History of Liver
• By the time patients have ascites associated with Disease?
their liver dysfunction, 60% have varices on EGD.
• Nasogastric tube placement is likely safe in patients Portal hypertension is defined as a hepatic venous pressure
with varices, but risks and benefits should be care- gradient greater than 5 mmHg and occurs due to increased
fully weighed and discussed with patient. structural resistance and decreased endogenous nitric oxide
• Risk factors associated with early re-bleeding and production [5]. Esophagogastric varices develop when the
poor outcomes include severe initial bleeding as hepatic venous pressure gradient (HPVG) rises above
defined by a hemoglobin less than 8 g/dL, gastric 10 mmHg.
variceal bleeding, thrombocytopenia, encephalopa- By the time cirrhosis is diagnosed or suspected based on
thy, alcohol-related cirrhosis, large varices, and stigmata of chronic liver disease (e.g., spider angiomas,
active bleeding during endoscopy. jaundice, pruritis, palmar erythema) and laboratory abnor-
• Antibiotics have a proven benefit in variceal bleed- malities, approximately 30–40% of patients will have varices
ing with decreased morbidity and mortality. [3]. The American College of Gastroenterology (ACG) rec-
ommends screening esophagogastroduodenoscopy (EGD) at
time of cirrhosis diagnosis; thus, many patients with a diag-
Cirrhosis occurs when damage to the liver results in scar nosis of cirrhosis will know if they have varices [5]. Of those
tissue (hepatic fibrosis), affecting liver function. Cirrhosis without varices at the time of diagnosis, another 10–15%
is the third leading cause of death in patients between the will develop varices each year [3]. By the time patients have
ages of 45 years and 64 years, with a median survival of ascites associated with their liver dysfunction, 60% have
9–12 years after diagnosis. In the United States, end-stage varices on EGD [3]. In advanced disease (e.g., Child-Pugh
liver disease is most often due to hepatitis C infections [1]. C), 85% of patients have varices [5, 6].
Gastrointestinal bleeding in patients with cirrhosis is com- Once varices are present, portal hypertension causes them
mon and carries a high mortality rate of approximately to grow in size by approximately 7% each year [4]. The size
15–30% [2–4]. of varices directly correlates with the risk of bleeding: 1–2%
without varices, 5% with small varices, and 15% with
medium or large (>5 mm) varices [3, 5]. When patients pres-
ent with gastrointestinal bleeding and have a history of vari-
ces, 70% of cases are due to ruptured esophageal varices,
usually at the GE junction [3, 5].
A. Graham
Department of Emergency Medicine, MedStar Washington
Hospital Center, MedStar Georgetown University Hospital, an I Place a Nasogastric Tube (NGT)
C
Washington, DC, USA
in Patients with Esophagogastric Varices?
A. C. Meltzer (*)
Department of Emergency Medicine, George Washington
Traditional dogma would suggest that blind placement of
University School of Medicine & Health Sciences,
Washington, DC, USA nasogastric tubes for nasogastric aspiration (NGA) or naso-
e-mail: ameltzer@mfa.gwu.edu gastric lavage (NGL) is unsafe in the advanced liver disease
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