eMedicine Specialties > Gastroenterology > Esophagus

Esophageal Varices: Differential Diagnoses & Workup

Author: Samy A Azer, MD, PhD, MPH, Professor of Medical Education, Chair of Medical Education Research and Development Unit, Faculty of Medicine, Universiti Teknologi MARA, Malaysia; Visiting Professor of Medical Education, Faculty of Medicine, University of Toyama, Japan; Former Senior Lecturer in Medical Education, Faculty Education Unit, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne and University of Sydney, Australia
Contributor Information and Disclosures

Updated: Jan 4, 2010

Differential Diagnoses

Budd-Chiari Syndrome
Portal Hypertension
Cirrhosis
Portal Vein Obstruction
Duodenal Ulcers
Schistosomiasis
Gastric Cancer
Wilson Disease
Gastric Ulcers
Mallory-Weiss Tear

Other Problems to Be Considered

Acute gastric erosions
Alcoholic cirrhosis
Hepatoportal arteriovenous fistula
Portal vein thrombosis
Splenic vein thrombosis
Venoocclusive disease

Gastric varices: These are the source of bleeding in 5-10% of patients with variceal hemorrhage. Higher rates are reported in patients with left-sided portal hypertension due to thrombosis of the splenic vein.

Portal hypertensive gastropathy: This is a common complication of cirrhosis and portal hypertension, but significant bleeding from this source is relatively uncommon.

Workup

Laboratory Studies

  • Complete blood cell (CBC) count: Results may show anemia, leucopenia, and thrombocytopenia in patients with cirrhosis. Anemia may be secondary to bleeding, nutritional deficiencies, or bone marrow suppression secondary to alcoholism. Many patients with portal hypertension have some degree of hypersplenism. The hematocrit value may be low in patients with upper abdominal bleeding.
  • Type and cross-match blood and order 6 units of packed red blood cells.
  • Prothrombin time (PT): Because the coagulation factors involved in this test are synthesized by the liver, impairment of the liver function may result in a prolonged prothrombin time.
  • Liver function tests: A mild elevation of the plasma activity of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) may occur in cirrhosis, although activity may be normal.
  • Blood urea, creatinine, and electrolytes: Blood urea and creatinine levels may be elevated in patients with esophageal bleeding. Drug treatment, cirrhosis, ascites, and blood loss may contribute to changes in the serum electrolytes of these patients.
  • Arterial blood gas (ABG) and pH measurements
  • Hepatic serology helps in the assessment of the cause of cirrhosis.

Imaging Studies

  • Ultrasonography of the upper abdomen may be indicated in those with esophageal varices, especially if biliary obstruction or liver cancer is suspected.

Other Tests

  • Rectal examination: Obtain a stool sample for visual inspection. A black, soft, tarry stool on the gloved examining finger suggests upper GI bleeding.

Procedures

  • Endoscopy is required at an early stage to formulate the management plan for those with esophageal varices. If active variceal bleeding or an adherent clot is observed, variceal hemorrhage can be diagnosed confidently. The presence of variceal red color signs (eg, cherry red spots, red whale markings, blue varices) indicates an increased risk of further bleeding.

More on Esophageal Varices

Overview: Esophageal Varices
Differential Diagnoses & Workup: Esophageal Varices
Treatment & Medication: Esophageal Varices
Follow-up: Esophageal Varices
References
Further Reading
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References

  1. Lubel JS, Angus PW. Modern management of portal hypertension. Intern Med J. Jan 2005;35(1):45-9. [Medline].

  2. Obara K. Hemodynamic mechanism of esophageal varices. Dig Endosc. Jan 2006;18(1):6-9.

  3. Ravindra KV, Eng M, Marvin M. Current management of sinusoidal portal hypertension. Am Surg. Jan 2008;74(1):4-10. [Medline].

  4. Gupta TK, Toruner M, Chung MK, Groszmann RJ. Endothelial dysfunction and decreased production of nitric oxide in the intrahepatic microcirculation of cirrhotic rats. Hepatology. Oct 1998;28(4):926-31. [Medline]. [Full Text].

  5. D'Amico G, Pagliaro L, Bosch J. Pharmacological treatment of portal hypertension: an evidence-based approach. Semin Liver Dis. 1999;19(4):475-505. [Medline].

  6. Bosch J, Abraldes JG, Groszmann R. Current management of portal hypertension. J Hepatol. 2003;38 suppl 1:S54-68. [Medline].

  7. Samonakis DN, Triantos CK, Thalheimer U, Patch DW, Burroughs AK. Management of portal hypertension. Postgrad Med J. Nov 2004;80(949):634-41. [Medline]. [Full Text].

  8. Chang YW. Indication of treatment for esophageal varices: who and when?. Dig Endosc. Jan 2006;18(1):10-5.

  9. [Best Evidence] Kumar A, Jha SK, Sharma P, et al. Addition of propranolol and isosorbide mononitrate to endoscopic variceal ligation does not reduce variceal rebleeding incidence. Gastroenterology. Sep 2009;137(3):892-901, 901.e1. [Medline].

  10. Lay CS, Tsai YT, Lee FY, et al. Endoscopic variceal ligation versus propranolol in prophylaxis of first variceal bleeding in patients with cirrhosis. J Gastroenterol Hepatol. Feb 2006;21(2):413-9. [Medline].

  11. [Best Evidence] Gluud LL, Klingenberg S, Nikolova D, Gluud C. Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials. Am J Gastroenterol. Dec 2007;102(12):2842-8; quiz 2841, 2849. [Medline].

  12. Arguedas MR, Heudebert GR, Eloubeidi MA, Abrams GA, Fallon MB. Cost-effectiveness of screening, surveillance, and primary prophylaxis strategies for esophageal varices. Am J Gastroenterol. Sep 2002;97(9):2441-52. [Medline].

  13. Garcia-Tsao G. Angiotensin II receptor antagonists in the pharmacological therapy of portal hypertension: a caution. Gastroenterology. Sep 1999;117(3):740-2. [Medline].

  14. Garcia-Tsao G. Portal hypertension. Curr Opin Gastroenterol. May 2000;16(3):282-9. [Medline].

  15. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. Sep 2007;102(9):2086-102. [Medline].

  16. Goulis J, Patch D, Burroughs AK. Bacterial infection in the pathogenesis of variceal bleeding. Lancet. Jan 9 1999;353(9147):139-42. [Medline].

  17. [Best Evidence] Groszmann RJ, Garcia-Tsao G, Bosch J, et al, for the Portal Hypertension Collaborative Group. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med. Nov 24 2005;353(21):2254-61. [Medline]. [Full Text].

  18. Nakamura S, Konishi H, Kishino M, et al. Prevalence of esophagogastric varices in patients with non-alcoholic steatohepatitis. Hepatol Res. Jun 2008;38(6):572-9. [Medline].

  19. Nevens F. Review article: a critical comparison of drug therapies in currently used therapeutic strategies for variceal haemorrhage. Aliment Pharmacol Ther. Sep 2004;20 Suppl 3:18-22; discussion 23. [Medline]. [Full Text].

  20. Patch D, Armonis A, Sabin C, et al. Single portal pressure measurement predicts survival in cirrhotic patients with recent bleeding. Gut. Feb 1999;44(2):264-9. [Medline]. [Full Text].

  21. Poo JL, Jimenez W, Maria Munoz R, et al. Chronic blockade of endothelin receptors in cirrhotic rats: hepatic and hemodynamic effects. Gastroenterology. Jan 1999;116(1):161-7. [Medline].

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Further Reading

Related eMedicine Topics

Clinical Trials

Clinical Guidelines

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Keywords

esophageal varices, esophageal varix, gastroesophageal varices, portal hypertension, esophageal bleeding, esophageal disease, cardioesophageal junction varices, esophagogastric varices, varices in the fundus and esophagus, varices at the gastroesophageal junction

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Contributor Information and Disclosures

Author

Samy A Azer, MD, PhD, MPH, Professor of Medical Education, Chair of Medical Education Research and Development Unit, Faculty of Medicine, Universiti Teknologi MARA, Malaysia; Visiting Professor of Medical Education, Faculty of Medicine, University of Toyama, Japan; Former Senior Lecturer in Medical Education, Faculty Education Unit, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne and University of Sydney, Australia
Samy A Azer, MD, PhD, MPH is a member of the following medical societies: American College of Gastroenterology, Association for Psychological Science, Gastroenterological Society of Australia, New York Academy of Sciences, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Waqar A Qureshi, MD, Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and Veterans Affairs Medical Center
Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Simmy Bank, MD, Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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