Gastrointestinal varices differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Non-bleeding varices are asymptomatic. Ruptured esophageal and gastric varices may lead to upper gastrointestinal bleeding and present with hematemesis. They must be differentiated from other causes of upper gastrointestinal bleeding such as peptic ulcer disease, esophagitis, gastritis, angiodysplasia, Dieulafoy's lesion, vascular ectasia, Mallory-Weiss tears, aorto-enteric fistulas and upper gastrointestinal tumors.

Differentiating Gastrointestinal Varices From Other Diseases

Differentials of ruptured varices

Ruptured esophageal and gastric varices may lead to upper gastrointestinal bleeding and present with hematemesis. It must be differentiated from other causes of upper gastrointestinal bleeding. The following table outlines the differentials:[1][2][3][4][5][6][7]

The following table summarizes the various causes of Upper gastrointestinal bleeding

Disease/Cause Bleeding manifestations Symptoms Risk factors Endoscopic findings
Hematemesis Melena Hematochezia Occult blood Abdominal
pain
Dysphagia Dyspepsia Weighloss
Ulcerative or erosive
Peptic ulcer disease + + + + + - + +/-
  • Ulcer with smooth, regular, rounded edges
  • Ulcer base often filled with exudate
  • Examination of the ulcer may reveal:
    • Active bleeding
    • Nonbleeding visible vessel
    • Adherent clot
    • Flat pigmented spot
    • Clean ulcer base
Esophagitis + + - + - + - -
  • Peptic esophagitis
    • The ulcerations are usually irregularly shaped or linear, multiple, and distal.
  • Pill-induced
  • Infectious esophagitis:
    • HSV – Discrete, superficial ulcers, with well-demarcated borders that tend to involve the upper or mid-esophagus; vesicles may be seen
    • CMV – Ulcers range from small and shallow to large (>1 cm) and deep; most patients have multiple lesions
    • Candida – Diffuse white plaques
    • HIV – Tends to involve the mid to distal esophagus, ulcers may be shallow or deep, and may be large
Gastritis/gastropathy + + - + + - + -
  • Erythematous mucosa
  • Superficial erosions
  • Nodularity
  • Diffuse oozing
Complications of portal hypertension
Esophagogastric varices + + + - + - - -
  • Vascular structures that protrude into the esophageal and/or gastric lumen
  • Findings associated with an increased risk of hemorrhage:
    • Longitudinal red streaks on the varices (red wale marks)
    • Cherry-colored spots that are flat and overlie varices
    • Raised, discrete red spots
Ectopic varices + + + - - - - -
Portal hypertensive gastropathy + + + + + - - -
  • Mosaic-like pattern that gives the gastric mucosa a "snakeskin" appearance
Vascular lesions
Angiodysplasia + + + + - - - -
  • Small (5 to 10 mm), flat, cherry-red lesions, often with a fern-like pattern of arborizing, ectatic blood vessels radiating from a central vessel.
Dieulafoy's lesion + + + - + - - -
  • Usually located in the proximal stomach
  • May have active arterial spurting from the mucosa without an associated ulcer or mass
  • If the bleeding has stopped, there may be a raised nipple or visible vessel without an associated ulcer
Gastric antral vascular ectasia + + + + + - - -
  • Longitudinal rows of flat, reddish stripes radiating from the pylorus into the antrum.
Traumatic or iatrogenic
Mallory-Weiss syndrome + + + - - - - -
  • Tear in the esophagogastric junction.
  • Usually singular and longitudinal, but may be multiple.
  • The tear may be covered by an adherent clot.
Foreign body ingestion + + + + - + - -
  • Psychiatric disorders
  • Dementia
  • Loose dentures
  • Visualization of the foreign body endoscopically.
Post-surgical anastomotic hemorrhage (marginal ulcers) + + + + + - + -
  • Ulceration/friable mucosa at an anastomotic site.
Aortoenteric fistula + + + - + - - -
  • Infectious aortitis
  • Prosthetic aortic graft
  • Atherosclerotic aortic aneurysm
  • Penetrating ulcers
  • Tumor invasion
  • Trauma
  • Radiation injury
  • Foreign body perforation
  • Endoscopy may reveal a graft, an ulcer or erosion at the site
  • Adherent clot, or an extrinsic pulsatile mass in the distal duodenum or esophagus.
Tumors
Upper GI tumors + + + + + + + +
  • Ulcerated mass in the esophagus, stomach, or duodenum.
  • In gastric malignancies:
    • The folds surrounding the ulcer crater may be nodular, clubbed, fused, or stop short of the ulcer margin
    • The margins may be overhanging, irregular, or thickened
  • Bleeding lymphoma may appear as
Miscellaneous
Hemobilia + + + - + - - - History of:
Hemosuccus pancreaticus + + + - + - + -
  • Blood or clot emanating from the ampulla.
  • Cross-sectional imaging or angiography is often required to confirm the diagnosis.

References

  1. Graham DY (2016). "Upper Gastrointestinal Bleeding Due to a Peptic Ulcer". N. Engl. J. Med. 375 (12): 1197–8. PMID 27653583. doi:10.1056/NEJMc1609017#SA2. 
  2. Chen ZJ, Freeman ML (2011). "Management of upper gastrointestinal bleeding emergencies: evidence-based medicine and practical considerations". World J Emerg Med. 2 (1): 5–12. PMC 4129733Freely accessible. PMID 25214975. 
  3. Kaufman DW, Kelly JP, Wiholm BE, Laszlo A, Sheehan JE, Koff RS, Shapiro S (1999). "The risk of acute major upper gastrointestinal bleeding among users of aspirin and ibuprofen at various levels of alcohol consumption". Am. J. Gastroenterol. 94 (11): 3189–96. PMID 10566713. doi:10.1111/j.1572-0241.1999.01517.x. 
  4. Lee EW, Laberge JM (2004). "Differential diagnosis of gastrointestinal bleeding". Tech Vasc Interv Radiol. 7 (3): 112–22. PMID 16015555. 
  5. Lee YT, Walmsley RS, Leong RW, Sung JJ (2003). "Dieulafoy's lesion". Gastrointest. Endosc. 58 (2): 236–43. PMID 12872092. doi:10.1067/mge.2003.328. 
  6. Ghosh S, Watts D, Kinnear M (2002). "Management of gastrointestinal haemorrhage". Postgrad Med J. 78 (915): 4–14. PMC 1742226Freely accessible. PMID 11796865. 
  7. Chalasani N, Clark WS, Wilcox CM (1997). "Blood urea nitrogen to creatinine concentration in gastrointestinal bleeding: a reappraisal". Am. J. Gastroenterol. 92 (10): 1796–9. PMID 9382039. 



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