Signs and symptoms

• Jaundice
• History of blood transfusion
• Intravenous drug abuse
• History of alcohol consumption
• Pruritus
• Hematemesis
• Melena
• Lethargy
• Increased irritability
• Altered sleep patterns
• Increased abdominal girth due to ascites
• Hematochezia
• Abdominal pain
• Fever

Signs of port systemic collateral formation

• Dilated veins in the anterior abdominal wall
• Venous pattern on the flanks
• Caput medusa
• Rectal hemorrhoids
• Ascites
• Paraumblical hernia

Signs of liver disease

• Ascites
• Jaundice
• Spider nevi
• Gynecomastia
• Dupuytren’s contracture
• Muscle wasting
• Palmar erythema
• Asterixis
• Testicular atrophy
• Splenomegaly

Causes

Prehepatic

• Portal vein thrombosis
• Splenic vein thrombosis
• Extrinsic compression by tumor
• Arteriovenous fistula

Intrahepatic presinusoidal and/ or postsinusoidal

• Hepatic cirrhosis
• Acute alcoholic hepatitis
• Primary biliary cirrhosis
• Congenital hepatic fibrosis
• Vitamin A toxicity
• Budd chiari syndrome
• Pelisosis hepatitis

Intrahepatic, predominantly presinusoidal

• Shistosomiasis
• Primary biliary cirrhosis
• Nodular regenerative hyperplasia
• Polycystic disease
• Hepatic metastasis
• Granulomatous disease (sarcoidosis and tuberculosis)

Treatment

Emergency treatment

• Each episode of variceal bleeding is associated with 30% mortality fever.
• Initial resuscitation with replacement of blood volume loss by packed or whole red blood cells or plasma expanders.
• Avoid intravascular volume and variceal overexpansion to prevent re bleeding.
• Prophylactic antibiotic use to decrease the rate of bacterial infections.

Pharmacotherapy

• Somatostatin- is an endogenous hormone that decreases the portal blood flow by vasoconstriction.
• Octreotide- it’s an analogue of somatostatin, also effective in reducing the complications of variceal bleeding after emergency sclerotherapy or variceal ligation
• Vasopressin- Most potent vasoconstrictor has more side effects.
• Terlipressin- has fewer adverse effects than vasopressin.

Endoscopic therapy

• Endoscopic therapy has the advantage of allowing specific therapy at the time of diagnosis.
• >80% of hemostasis can be achieved.
• Endoscopic injection sclerotherapy involves injecting sclerosant solution like sodium morrhuate, sodium tetradecyl sulfate, and ethanolamine oleate into the bleeding veins.

Endoscopic variceal ligation

Other interventions

• Balloon tube tamponade
• Minnesota tube

Primary prophylaxis

• Beta blockers- Propranolol and Nadolol
• Vasodilators- Isosorbide mononitrate
• Combination therapy- Propranolol and Isosorbide mononitrate
• Prophylactic sclerotherapy
• Prophylactic endoscopic variceal ligation

Surgical care

Decompressive shunts

• Total portal systemic shunts
• Partial portal systemic shunts
• Selective shunts

Devascularization procedures

• Splenectomy
• Liver transplantation