Signs and Symptoms

Recognition of variceal hemorrhage in the emergency department is the first step toward proper management. Upper GI hemorrhage in patients with known liver disease should be treated as variceal bleeding until proven otherwise. The classic signs of upper GI hemorrhage are melena and hematemesis. Of patient presentations of melena or hematemesis, 5%-10% are caused by varices,¹¹ but among patients with portal hypertension, ruptured varices account for 70% of all upper GI bleeding episodes.^12,13

Several other signs and symptoms can be helpful in diagnosing variceal hemorrhage. Melena is typically associated with upper GI hemorrhage (proximal to the ligament of Treitz), but hematochezia may be a sign of brisk upper GI hemorrhage. Melena has been found to be present in 70%-80% of patients with upper GI hemorrhage, while hematochezia reportedly occurs in 15%-20% of these patients.³ Given these findings, all patients suspected of GI bleeding should have a rectal exam immediately. In addition, patients with liver disease and symptoms of anemia, including presyncope or syncope, fatigue, chest pain, or shortness of breath, should receive prompt evaluation for variceal hemorrhage.

Diagnostic Tests

Diagnosis of variceal hemorrhage often cannot definitively be made in the ED, but should be suspected on the basis of past medical history, history of present illness, and physical findings. GI hemorrhage in a cirrhotic patient should be assumed to be variceal until proven otherwise. In these patients, a number of diagnostic tests should be employed and may be useful in guiding treatment. Initial vital signs have been shown to have prognostic value. Specifically, shock (systolic blood pressure less than 100 mm Hg or heart rate greater than 100 bpm) confers a poorer prognosis for patients with upper GI bleeding, with mortality as high as 30% overall.³