How is a ruptured esophageal varix diagnosed in a cirrhotic patient presenting with acute upper gastrointestinal bleeding (hematemesis, massive melena, hypotension, tachycardia) after hemodynamic stabilization?

Diagnosis of Ruptured Esophageal Varices

Endoscopy is the definitive diagnostic method and should be performed in all patients with suspected esophageal variceal bleeding after initial hemodynamic stabilization, ideally within 12 hours of presentation. 1

Clinical Suspicion and Initial Assessment

Suspect variceal bleeding in any cirrhotic patient presenting with:

• Hematemesis (vomiting blood) or massive melena (black, tarry stools) 1
• Hypotension and tachycardia indicating hemodynamic instability 1
• Physical stigmata of chronic liver disease: jaundice, ascites, hepatic encephalopathy, splenomegaly, abdominal collateral vessels, lower extremity edema, or spider angiomas 1

The presence of these clinical features in a patient with known or suspected portal hypertension should trigger immediate vasoactive drug therapy before endoscopy is performed, as early pharmacological intervention improves outcomes 1.

Definitive Endoscopic Diagnosis

Upper endoscopy establishes the diagnosis when it demonstrates any of the following findings: 1

• Active bleeding from a varix (blood spurting or oozing from the variceal column)
• White nipple sign (fibrin plug overlying a varix, indicating recent rupture)
• Blood clot adherent to a varix (suggests this as the bleeding source)
• Varices present with blood in the stomach but no other identifiable bleeding source (diagnosis by exclusion)

Timing of Endoscopy

• Perform endoscopy within 12 hours after initial resuscitation and achievement of hemodynamic stability 1, 2
• Earlier endoscopy (as soon as possible after resuscitation) is indicated for patients with ongoing hemodynamic instability or massive bleeding 2, 3
• Do not delay vasoactive drug therapy while waiting for endoscopy—start terlipressin, octreotide, or somatostatin immediately upon clinical suspicion 1, 2

Pre-Endoscopy Optimization

Administer erythromycin 250 mg IV 30–120 minutes before endoscopy to improve gastric visualization by promoting gastric emptying, unless contraindicated by QT prolongation 1, 2

Resuscitation Priorities Before Diagnosis

While arranging urgent endoscopy, simultaneously initiate:

• Restrictive transfusion strategy: Target hemoglobin 7–9 g/dL to avoid increasing portal pressure through excessive volume expansion 1, 2
• Crystalloid fluid resuscitation for initial volume replacement while awaiting blood products 1, 2
• Vasoactive drugs immediately: Terlipressin (preferred), octreotide, or somatostatin started as soon as variceal bleeding is suspected 1, 2
• Antibiotic prophylaxis: Ceftriaxone 1 g IV daily (maximum 7 days) reduces mortality and bacterial infections 1, 2
• Airway protection in patients with active hematemesis or altered mental status to prevent aspiration 2

Diagnostic Pitfalls to Avoid

• Do not wait for endoscopy to start vasoactive drugs—up to 30% of cirrhotic patients with upper GI bleeding have non-variceal causes, but empiric therapy for varices should begin immediately 1, 2
• Nasogastric tube placement may have prognostic value but a negative aspirate does not exclude variceal bleeding (3–16% of patients with upper GI bleeding may have negative aspirates) 4
• Do not over-transfuse: Maintaining hemoglobin >9 g/dL increases portal pressure and rebleeding risk 1, 2

Alternative Diagnostic Approaches When Endoscopy Is Not Feasible

If endoscopy cannot be performed due to massive ongoing bleeding or clinical instability:

• CT angiography can localize the bleeding source 4
• Visceral angiography allows simultaneous diagnosis and treatment via embolization in unstable patients with overt large bleeding 4

However, these imaging modalities are second-line; endoscopy remains the gold standard for both diagnosis and immediate therapeutic intervention 1.