A condition that you may encounter is bleeding from the esophagus. For the Physician Assistant Exam (PANCE), be aware of the three types of esophageal bleeding — Mallory-Weiss tears, Boerhaave’s syndrome, and esophageal varices.
Mallory-Weiss tears
Mallory-Weiss tears are tears or lacerations in the distal part of the esophagus. The most common test scenario involves a person with a history of recurrent retching or vomiting, perhaps following an alcoholic binge. The key is in the history. In a test question, look for someone with a history of bulimia or alcohol abuse who presents with acute hematemesis.
You diagnose Mallory-Weiss by endoscopy. If the patient has areas of active bleeding, they can be treated with either cautery or a sclerosing agent.
Boerhaave’s syndrome
Boerhaave’s syndrome is usually a perforation in the distal esophagus. Increases in intra-esophageal and intrathoracic pressure, often secondary to vomiting and retching, frequently precede the perforation. Large meals and alcohol intake are contributing factors. Symptoms include severe chest and abdominal pain and the rapid development of fever, tachypnea, and shock. The treatment is surgical intervention, parenteral feedings, and IV antibiotics.
Esophageal varices
Esophageal varices can present with painless, acute hematemesis, usually in someone with a history of cirrhosis/end-stage liver disease. As a consequence of increased portal venous pressures, these veins rupture, leading to bleeding. Esophageal varices is an emergent condition. For the PANCE, here are the take-home points:
For the management of esophageal varices, familiarize yourself with certain medications. Order an intravenous proton pump inhibitor as well as an intravenous octreotide (Sandostatin) infusion. (This is different from the subcutaneous octreotide you may order in someone with acute kidney failure in the setting of liver disease.) If you’re given the option of using intravenous vasopressin (Pitressin), that’s a good choice as well.
You want to volume resuscitate these patients, usually with isotonic saline. Check a CBC and PT/INR to make sure that the liver can clot the blood. In an acute bleed and an elevated INR, the person also needs fresh frozen plasma (FFP) — vitamin K is not enough to do the trick, because the liver is unable to utilize the vitamin K to synthesize clotting factors because of the cirrhosis.
The diagnosis and management is done via endoscopy. You may see longitudinal red wale markings. The area is usually sclerosed, or band ligation is done.
Which of the following would be contraindicated in the emergent management of esophageal varices?
(A) Intravenous vasopressin
(B) Fresh frozen plasma
(C) Subcutaneous octreotide
(D) Intravenous normal saline
(E) Intravenous proton pump inhibitor
The correct answer is Choice (C). With acute esophageal varices, you want to use intravenous octreotide as a continuous infusion, not give it subcutaneously. All the other choices are inappropriate in this situation.