Esophageal Varices Clinical Presentation

• Symptoms of liver disease

  • Weakness, tiredness, and malaise
  • Anorexia
  • Sudden and massive bleeding with shock on presentation
  • Nausea and vomiting
  • Weight loss - Common with acute and chronic liver disease, mainly due to anorexia and reduced food intake, and regularly accompanies end-stage liver disease, when a loss of muscle mass and adipose tissue is often a striking feature
  • Abdominal discomfort and pain - Usually felt in the right hypochondrium or under the right lower ribs (front, side, or back) and in the epigastrium or the left hypochondrium
  • Jaundice or dark urine
  • Edema and abdominal swelling
  • Pruritus - Usually associated with cholestatic conditions, such as extrahepatic biliary obstruction, primary biliary cirrhosis, sclerosing cholangitis, cholestasis of pregnancy, and benign recurrent cholestasis
  • Spontaneous bleeding and easy bruising
  • Encephalopathic symptoms - Disturbance of the sleep-wake cycle, deterioration in intellectual function, memory loss and, finally, inability to communicate effectively at any level, personality changes, and, possibly, display of inappropriate or bizarre behavior
  • Impotence and sexual dysfunction
  • Muscle cramps - Common in patients with cirrhosis
• Past medical history

  • Previous jaundice suggests the possibility of a previous acute hepatitis, hepatobiliary disorder, or drug-induced liver disease.
  • Recurrence of jaundice suggests the possibility of reactivation, infection with another virus, or the onset of hepatic decompensation.
  • Patients may have a history of blood transfusion or administration of various blood products.
  • A history of schistosomiasis in childhood may be obtained from patients in whom infection is endemic.
  • Intravenous drug abuse
• Family history of hereditary liver disease such as Wilson disease
• Lifestyle and history of diseases, such as nonalcoholic steatohepatitis (NASH), diabetes mellitus, and hyperlipidemia
• Risk factors for upper GI bleeding

  • Bleeding diathesis
  • Peptic ulcer disease
  • Use of alcohol or nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Documented cirrhosis
  • Documented episodes of GI tract bleeding
  • History of recent vigorous retching or emesis before an attack of hematemesis or melena

• Pallor may suggest active internal bleeding.
• Low blood pressure, increased pulse rate, and postural drop of blood pressure may suggest blood loss.
• Parotid enlargement may be related to alcohol abuse and/or malnutrition.
• Cyanosis of the tongue, lips, and peripheries due to low oxygen saturation may be observed.
• Patients may experience dyspnea and tachypnea.
• A hyperdynamic circulation with flow murmur over the pericardium may be present.
• Jaundice may be present because of impairment of liver function.
• Look for telangiectasis of the skin, lips, and digits.
• Gynecomastia in males results from failure of the liver to metabolize estrogen, resulting in a sex hormone imbalance.
• Fetor hepaticus occurs in portosystemic encephalopathy of any cause (eg, cirrhosis).
• Palmar erythema and leuconychia may be present in patients with cirrhosis.
• Ascites, abdominal distention due to accumulation of fluid, may be present. Ascites may be associated with peripheral edema and may involve the abdominal wall and genitalia.
• Numerous dilated veins radiating out of the umbilicus may be observed. Distended abdominal wall veins may be present, with the direction of venous flow away from the umbilicus.
• The liver may be small.
• Splenomegaly occurs in portal hypertension.
• Testicular atrophy is common in males with cirrhosis, particularly those with alcoholic liver disease or hemachromatosis.
• Venous hums, continuous noises audible in patients with portal hypertension, may be present as a result of rapid turbulent flow in collateral veins.
• During the rectal examination, obtain a stool sample for visual inspection. A black, soft, tarry stool on the gloved examining finger suggests upper GI bleeding.

Diseases that interfere with portal blood flow can result in portal hypertension and the formation of esophageal varices. Causes of portal hypertension usually are classified as prehepatic, intrahepatic, and posthepatic.

• Prehepatic

  • Splenic vein thrombosis
  • Portal vein thrombosis
  • Extrinsic compression of the portal vein
• Intrahepatic

  • Congenital hepatic fibrosis
  • Hepatic peliosis
  • Idiopathic portal hypertension
  • Sclerosing cholangitis
  • Tuberculosis
  • Schistosomiasis
  • Primary biliary cirrhosis
  • Alcoholic cirrhosis
  • Hepatitis B virus–related and hepatitis C virus–related cirrhosis
  • Wilson disease
  • Hemachromatosis
  • Alpha-1 antitrypsin deficiency
  • Chronic active hepatitis
  • Fulminant hepatitis
• Posthepatic

  • Budd-Chiari syndrome
  • Thrombosis of the inferior vena cava
  • Constrictive pericarditis
  • Venoocclusive disease of the liver