Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:57

1196 Portal Hypertensive Bleeding

Signs and Symptoms

■Compensated or decompensated liver disease prior to index bleed

■Manifestations include hematemesis and/or melena

■Bleeding brisk and may be exsanguinating from esophageal or gastric

varices; bleeding from portal hypertensive gastropathy tends to be

chronic

tests

Basic Studies

■blood: abnormal LFTs, including decreased albumin, increased

bilirubin and increased INR, indicating various degrees of hepatic

synthetic dysfunction

■Hemoccult positive stool

Other Tests

■imaging:

➣ultrasound or CT scan showing presence of cirrhosis, including

evidence of portal hypertension

■endoscopy:

➣showing esophageal and/or gastric varices, with either blood in

the lumen or evidence of active bleeding from the varix; exclusion

of ulcer or other disease also important

differential diagnosis

■esophageal varices

■gastric varices

■portal hypertensive gastropathy

■peptic ulcer

■Dieulofoy’s lesion

management

What to Do First

■patients suspected of bleeding from varices require hospitalization

and immediate endoscopy

■adequate venous access established

■resuscitation with restoration of blood volume with blood and fresh

frozen plasma guided by CVP and urine output

General Measures

■care taken not to overexpand the plasma volume, which may increase

portal pressure and exacerbate bleeding