Esophageal Varices

When a patient with cirrhosis vomits bright red blood, the bleeding source isn't an ulcer — it's fragile, ballooned veins under massive portal pressure, and the management priorities are completely different.

Esophageal varices develop when portal hypertension from liver cirrhosis forces blood into collateral venous pathways, including the submucosal veins of the esophagus. These thin-walled vessels were never designed for high-pressure flow, so they dilate and become extremely fragile. Rupture is the feared complication — it produces sudden, massive, painless hematemesis that can be fatal within minutes. Immediate priorities include airway protection (risk of aspiration from large-volume hematemesis), two large-bore IVs, volume resuscitation with isotonic crystalloids, and blood product administration. Octreotide (a somatostatin analog) is given IV to reduce portal pressure by constricting splanchnic blood flow. Endoscopic band ligation or sclerotherapy is the definitive intervention to stop active bleeding. If endoscopy fails, a balloon tamponade device (Sengstaken-Blakemore or Minnesota tube) may be placed temporarily — the nurse must monitor for airway obstruction and esophageal necrosis. Beta-blockers (propranolol, nadolol) are used prophylactically to prevent first or recurrent bleeding by lowering portal pressure. Ammonia levels must be monitored because swallowed blood is a protein load that can precipitate hepatic encephalopathy.

Key Distinctions

Don't confuse variceal bleeding (painless, massive hematemesis from portal hypertension) with peptic ulcer bleeding (often epigastric pain, coffee-ground emesis). Balloon tamponade is a temporary bridge, not treatment — it buys time for endoscopy. Students forget that swallowed blood acts as a protein load triggering hepatic encephalopathy; lactulose is given to prevent this complication, not just as a laxative.

Clinical Pearl

Blood in the gut is protein in the gut. After a variceal bleed, think lactulose — the liver can't clear the ammonia, and encephalopathy is the next crisis waiting to happen.