Quick Recertification Series

C HR I ST I N GI O R DA N O, MPAS, PA-C ; A M Y M ERCA NT I NI KLI NG LER, M S, PA-C

ESOPHAGEAL VARICES hematochezia, melena, hematem- >>questions & answers<<

esis, hypotension, and tachycardia.
›GENERAL FEATURES • Stigmata of liver disease such as 1. Mr. Smith is a 60-year-old male
• Esophageal varices are defined as spider nevi, palmar erythema, jaun- with a history of alcohol abuse. He
dilated esophageal veins. dice, and clubbing of the nails may presents to the clinic after having
• Varices are most often caused by indicate long-standing liver failure. an ultrasound and abdominal CT
scan with findings suggestive of liver
portal hypertension, which is an • Because esophageal varices do not be- cirrhosis and splenomegaly. He asks
increased pressure gradient between come evident until they result in GI when he should be screened for the
the wedged hepatic vein pressure bleed, screening with esophagogas- dilated veins he read about online. The
and the free hepatic vein pressure. troduodenoscopy (EGD) in patients correct answer is
• The most common cause of portal with portal hypertension is vital. a. In 1 year
hypertension is liver cirrhosis. • Patients with cirrhosis should un- b. After he has symptoms of GI
Rarer causes of portal hypertension dergo an EGD screening when the bleeding, including melena and
include portal or splenic vein throm- condition is first diagnosed. hematemesis
c. As soon as possible
bosis, splenomegaly from lympho-
d. He does not require screening
ma, schistosomiasis, Budd-Chiari ›DIAGNOSIS
syndrome, and cardiac diseases • Upper endoscopy utilizing EGD Answer: c
leading to vascular congestion. is the gold standard for diagnosing Explanation: Mr. Smith has a new diag-
• The most serious complication of and treating esophageal varices. nosis of cirrhosis and has demonstrated
esophageal varices is bleeding, which • CT or MRI can detect varices and portal hypertension as he has splenom-
occurs in about 30% of patients. evaluate the portal system but are egaly. He should have an EGD screening
Each episode of bleeding carries a generally not used for acute diagnosis. as soon as possible. If grade II or greater
varices are discovered, prophylaxis with
mortality rate of approximately 20%. • Laboratory testing should include a beta-blocker will be necessary.
• Other potentially life-threatening CBC, partial thromboplastin time
complications related to variceal (PTT), international normalized ra-
2. Mrs. Jones is a 48-year-old female
bleeding include aspiration pneumo- tio (INR), prothrombin time (PT), with a history of cirrhosis secondary
nia, sepsis, hepatic encephalopathy, electrolytes, and liver function. In to hepatitis C who presents to the
and renal failure. patients with esophageal varices, emergency department complaining
the CBC often shows anemia and of melena for the past 2 days. Her he-
›CLINICAL ASSESSMENT thrombocytopenia. The hematocrit moglobin level is 8.5 g/dL, down from
• Esophageal varices should be sus- level is often followed to track treat- a baseline of 10 g/dL. She received
a diagnosis of grade I varices in the
pected in any patient with an upper ment progress. Serum electrolytes
past. Which of the following should her
GI bleed and known liver cirrhosis should be followed if treatment for treatment include?
or with other diseases that can GI bleed is instituted.
a. Octreotide and PPI drip with antibiotics
cause portal hypertension. b. Emergent EGD for possible banding
• History should assess for risk fac- ›TREATMENT or sclerotherapy of bleeding varices
tors that increase the likelihood • Mainstay therapy consists of band c. Aggressive resuscitation with two
of bleeding, including GI bleed, ligation and sclerotherapy. units of packed red blood cells
known large varices, liver failure, • Patients with an upper GI bleed sec- (pRBCs) and IV fluids
continued alcohol use, and presence ondary to varices should undergo d. A and B
e. All of the above
of “red wale” signs on endoscopy. emergent EGD and be monitored
• Physical examination findings in pa- closely for continued decreases in Answer: d
tients with a GI bleed secondary to hemoglobin levels and hypotension. Explanation: Aggressive resuscitation
esophageal varices include positive • Medications used to treat an active should be avoided in patients with
variceal hemorrhage include esophageal varices, as this can lead
–– Octreotide bolus (Sandostatin, to increased portal pressure and,
This Quick Recertification Series is not meant generics) followed by drip to therefore, continued or new GI bleed-
to replace in-depth studying for the recertification ing. Patients should not be transfused
decrease portal pressure
exam and should be used only as an adjunct. with pRBCs beyond a hemoglobin level
Furthermore, the information contained here
–– Proton pump inhibitor (PPI) bo- of 8 g/dL, and IV fluids should be used
may not be sufficient to provide diagnosis and lus followed by drip to suppress with caution.
treatment in the clinical setting. acid and prevent rebleed

www.jaapa.com • July 2011 • 24(7) • JAAPA 53

 Quick Recertification Series

–– Antibiotics with gram-negative have repeat EGD in 2 to 3 years. >>question & answer<<
coverage to reduce infectious • Lifestyle modifications, including
complications discontinuing alcohol use and main- 1. A patient presents with intensely
–– Beta-blockers, which should be taining a healthy weight, will help. pruritic vesicles on the lateral aspects
started as soon as hemodynami- of the fingers of the bilateral hands.
cally feasible. Culture and potassium hydroxide
• Transfusion of packed RBCs is dis- DYSHIDROSIS (KOH) test results are negative. The
first-line treatment for this patient is
couraged unless the hemoglobin lev-
a. Topical corticosteroid
el is less than 8 g/dL, as aggressive ›GENERAL FEATURES b. Vaseline
volume resuscitation can increase • Dyshidrosis—also known as pompho- c. Antibiotic ointment and sterile
portal pressure and precipitate new lyx, dyshidrotic eczema, or dyshidrot- dressing
or continued variceal bleeding. ic dermatitis—is an intensely pruritic d. PUVA therapy
• Band ligation is generally consid- dermatitis that affects the palms of the
ered more effective than sclero- hands, soles of the feet, lateral aspects Answer: a
therapy at preventing rebleeding; of the feet and toes and, frequently, Explanation: A topical corticosteroid
preparation is the standard initial treat-
however, banding may be difficult the lateral aspects of the fingers. It is
ment for dyshidrosis.
to visualize during an active bleed. both chronic and recurrent.
• After the initial treatment, patients • No clear etiology for dyshidrosis has
should be retreated with EGD been established, but it is believed
approximately every 2 weeks until to be multifactorial. Conditions as- • Punch biopsies are usually not
the varices are eradicated. Three sociated with episodes of dyshidrosis indicated, except in treatment-
to 6 months later, EGD should be include emotional stress; seasonal resistant cases.
performed again to confirm eradica- changes; atopy or familial atopy;
tion. If no further band ligation is dermatitis resulting from exposure ›TREATMENT
required, surveillance EGD may be to chromium, cobalt, and nickel; • The goals of treatment are to reduce
repeated after 6 to 12 months. hyperhidrosis; or frequent exposure the symptoms and complications
• In refractory cases, a transjugular to fluids. and to improve the appearance of
intrahepatic portosystemic shunt the affected areas.
(TIPS) should be considered. ›CLINICAL ASSESSMENT • Standard treatment begins with
Because TIPS can decrease life • Dyshidrosis commonly manifests with topical class I or II corticosteroids.
expectancy in patients with cirrho- intensely pruritic skin eruptions on Systemic corticosteroids may be
sis, bleeding should be controlled the palms and/or lateral aspects of the beneficial in more severe cases.
with banding when possible; TIPS fingers, soles, and toes that progress • Oral or topical antihistamines may
should also be avoided in patients to form vesicles. These vesicles cause be beneficial, particularly in reducing
who are not transplant candidates. erosions and fissures as they resolve pruritus and minimizing scratching.
• Patients with medium to large over the course of 1 to 3 weeks. • Treatment with psoralen plus
varices should be placed on a beta- • Patients may experience pain, espe- ultraviolet A (PUVA) or UVA
blocker with a goal resting heart cially if large vesicles are present. treatments, tacrolimus (Prograf,
rate of 50 to 60 beats per minute to • Dyshidrosis should be suspected in Protopic, generics) or pimecroli-
reduce the risk of bleeding. patients with a history of hyper- mus (Elidel), or botulinum toxin A
• Those who have small varices at the hidrosis, atopic conditions (eg, (Botox, Dysport) injections may be
initial screening should have repeat allergies, asthma), stress, and/or considered if the patient is resistant
EGD after 1 year to assess for exposure to certain metals. to standard first-line therapies.
growth; those who do not have va- • Adjunctive treatments include stress
rices at the initial screening should ›DIAGNOSIS reduction, avoidance of frequent
• Dyshidrosis is usually diagnosed bathing and hand-washing that
clinically. may exacerbate symptoms, avoid-
Christin Giordano practices in the Division of • Bacterial culture and potassium hy- ance of scratching affected areas,
Hepatology, Center for Liver Diseases, University droxide (KOH) test are often used and regular use of protective hand
of Miami in Miami, Florida. Amy Mercantini to rule out bacterial infection and creams. jaapa
Klingler practices primary care at the Salmon
River Clinic in Stanley, Idaho. The authors have
fungal infection, respectively.
indicated no relationships to disclose relating to • Allergic patch testing may be used to Dawn Colomb-Lippa, PA-C; Amy Mercantini
the content of this article. rule out allergic contact dermatitis. Klingler, MS, PA-C, department editors

54 JAAPA • July 2011 • 24(7) • www.jaapa.com