Rosen & Barkin's 5-Minute Emergency Medicine Consult (758 page)

• Somatostatin or octreotide (if somatostatin not available)
  
• Norfloxacin PO or ciprofloxacin IV
  

• Erythromycin
  
• Ceftriaxone
  

FOLLOW-UP

• ICU admission for actively bleeding varices
  
• Recent history of variceal bleeding
  
• High risk for early rebleeding:
  
  • Age >60 yr, renal failure, initial hemoglobin count <8
    

Nonbleeding varices

• Continued hemorrhage requiring surgery or higher level of care
  
• Liver transplant
  

• Timely outpatient GI follow-up:
  
  • Will need annual surveillance endoscopies
    
• Medication and lifestyle modifications
  

• Intubate early, especially in patients with hepatic encephalopathy or hemodynamic instability.
  
• Begin prophylactic antibiotics prior to endoscopy. Improves survival
  
• In US, octreotide has replaced vasopressin owing to better side-effect profile. If vasopressin is required, use IV nitroglycerin infusion concomitantly to reduce end-organ ischemia.
  
• Control the airway prior to placement of balloon tamponade device, which provides only a temporizing measure prior to surgery or TIPS
  
• Hematochezia in a hemodynamically unstable patient is an upper GI bleed until proven otherwise.
  
• Consult your GI specialists early, since endoscopy is the 1st-line diagnostic and therapeutic procedure.
  

• Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis.
  Am J Gastroenterol.
  2007;102:2086–2102.
  
• Nevens F. Review article: A critical comparison of drug therapies in currently used therapeutic strategies for variceal haemorrhage.
  Aliment Pharmacol Ther
  . 2004;20(suppl 3):18–22.
  
• Sass DA, Chopra KB. Portal hypertension and variceal hemorrhage.
  Med Clin N Am
  . 2009;93:837–853.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Cirrhosis
  
• Gastrointestinal Bleeding
  

CODES

• 456.0 Esophageal varices with bleeding
  
• 456.1 Esophageal varices without mention of bleeding
  
• 456.21 Esophageal varices in diseases classified elsewhere, without mention of bleeding
  

BASICS

• Injury to the walls of blood vessels from inflammation:
  
  • Ischemia and necrosis
    
  • Aneurysms and hemorrhage
    
  • Immunopathologic mechanisms:
    
    • Deposition of circulating antigen–antibody complex and complement fixation
      
    • Cell-mediated hypersensitivity
      
    • Granulomatous tissue reaction from persistent inflammation and formation of epithelioid giant cells
      
• The vasculitides represent a wide group of disorders:
  
  • Multisystem disease with constitutional symptoms and inflammatory lab indices
    
  • Secondary to another disorder or trigger, or primary if vasculitis is the principal feature and the cause is unknown
    
  • Multiple factors determine presentation:
    
    • The size of the affected blood vessels
      
    • The specific distribution, severity, and duration of the inflammation
      
    • Degree of permeability or occlusion of the affected vessels
      
• 1 out of 2,000 adults has some form of vasculitis
  

• Classification is evolving and is increasingly based on presence or absence of antineutrophil cytoplasmic antibodies (ANCA).
  
• Traditional classification is based on vessel size.
  
• Large vessel vasculitides:
  
  • Temporal (giant cell) arteritis:
    
    • Granulomatous arteritis of the aorta and its major branches often involving the temporal artery
      
    • Patients >50 yr
      
  • Takayasu arteritis:
    
    • Granulomatous inflammation of the aorta and its major branches
      
    • Usually occurs in patients <50 yr
      
• Medium vessel vasculitides:
  
  • Polyarteritis nodosa (PAN):
    
    • Small- and medium-sized arteritis
      
    • Common distribution includes vessels supplying the muscles, joints, intestines, nerves, kidneys, and skin
      
    • Most common in middle age
      
  • Kawasaki disease (mucocutaneous lymph node syndrome):
    
    • Coronary arteries are often involved and involves large-, medium-, and small-sized arteries
      
    • Usually occurs in children
      
  • Isolated CNS vasculitis
    
• Small vessel vasculitides:
  
  • Granulomatosis with polyangiitis (Wegener granulomatosis):
    
    • Necrotizing vasculitis affecting small- to medium-sized vessels
      
    • Granulomatous inflammation of the upper and lower respiratory tract and glomerulonephritis
      
  • Microscopic polyangiitis:
    
    • Necrotizing affecting small vessels
      
    • Glomerulonephritis is very common.
      
    • Pulmonary capillaritis often occurs.
      
  • Churg–Strauss syndrome (allergic granulomatosis):
    
    • Small- and medium-sized arteries
      
    • Mainly lungs, GI, and nerves
      
    • Can also involve heart, skin, and kidney
      
  • Henoch–Schönlein purpura:
    
    • Most patients <20 yr
      
  • Buerger disease (thromboangiitis obliterans):
    
  • Hypersensitivity vasculitis:
    
    • Recurring inflammation and thrombosis of small and medium arteries and veins of the hands and feet
      
    • Typically between 20 and 40 yr and male
      
  • Secondary vasculitides:
    
    • Bacterial infections:
      
      • Streptococcal, tuberculous, staphylococcal, Lyme disease, leprosy
        
    • Viral infections:
      
      • Hepatitis B or C, CMV, HSV, HIV
        
    • Rickettsial infections
      
    • Drug related
      
    • Connective tissue disease:
      
      • Systemic lupus erythematosus
        
      • Rheumatoid arthritis
        
      • Behcçet disease
        
    • Malignancy:
      
      • Hairy cell leukemia
        
      • Lymphoma
        
    • Mixed cryoglobulinemia
      
    • Goodpasture syndrome
      
    • Serum sickness
      

DIAGNOSIS

• Systemic complaints are common early in the presentation of vasculitis, before vascular-related complications occur:
  
  • Fever, fatigue, weight loss, diffuse aches and pains
    
• Signs of arterial insufficiency:
  
  • Ischemic pain:
    
    • Angina, abdominal angina, claudication, jaw claudication
      
  • Neurologic ischemia:
    
    • Headache, TIA, stroke, visual and sensorineural hearing loss, hallucinations, neuropathy, vision loss
      
  • Renal ischemia:
    
    • Severe or resistant HTN
      
  • Dermatologic ischemia:
    
    • Classic skin findings include palpable purpura.
      
    • Nodular lesions, ulcers, livedo reticularis, and digital ischemia may also be seen
      
  • Oligoarthritis
    
  • Ocular ischemia:
    
    • Diplopia, retinal hemorrhages, scleritis, and episcleritis
      
  • Respiratory tract:
    
    • Sinusitis, epistaxis, nasal and oral ulcerations, strawberry tongue
      
  • GI ischemia:
    
    • Hematochezia, melena, hematemesis, peritonitis, hepatitis
      
  • Cardiac:
    
    • Coronary artery aneurysms, myocarditis, pericarditis, valvular disease, CHF