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doi:10.1111/jgh.12827
E D U C AT I O N A N D I M A G I N G
Hepatology: Esophageal bullae and hemorrhage in portal hypertension
Figure 1
Esophageal hemorhagic bullae on upper endoscopy.
A 60-year-old man presented with altered mental status and lethargy. He had a liver transplant 22 years ago due to cryptogenic cirrhosis with recurrence of cirrhosis in his allograft. The patient reported having dark stools and coffee ground like emesis. On admission, the patient was hypotensive with anemia, metabolic acidosis and acute kidney injury. The patient was started on octreotide and a proton pump inhibitor. On endoscopy, there were diffuse hemorrhagic bullae with ulceration in the esophagus (Figure 1). With gentle pressure to the bullae, there would be minor oozing of blood. No endoscopic intervention was performed. The patient expired within 36 hours of admission from multi-organ failure. An autopsy revealed diffuse patches of blood that elevated the mucosa. The tissue was extremely friable and would disintegrate upon removal. Histological examination of the esophagus revealed numerous subepithelial hemorrhages that elevated the squamous epithelium with dilated veins in the submucosa (Figure 2). The intact squamous epithelium did not reveal any evidence of acute inflammation, viral change, bacteria, or fungi. There was no underlying vasculitis or granulomatous inflammation. The subepithelial vascular lakes were most likely a result of esophageal varices with rupture and significant upper gastrointestinal hemorrhage. Gastroesophageal varices are a result of portal hypertension and the formation of portosystemic collaterals. They can seen in about 50% of patients with cirrhosis. Cirrhotic patients with varices will
Figure 2
Subepithelial hemorrhage on histology (H&E stain).
have an elevated hepatic venous pressure gradient of at least 10-12 mmHg. Esophagogastroduodenoscopy has remained the main modality for diagnosing varices in a cirrhotic patient. They can be classified into 3 sizes; small, medium and large. Small varices generally completely flatten with air insufflation. Medium and large varices are more tortuous and full and are distinguished by how much of the esophageal lumen they occupy. It has been recommended that all patients with a new diagnosis of cirrhosis have an upper endoscopy to screen for varices. The management of esophageal varices can be endoscopic, pharmacologic, or radiologic. This case presents a unique endoscopic presentation of a significant esophageal variceal bleed. The hemorrhagic bullae represented pools of blood that were trapped under the squamous epithelium of the esophagus as confirmed by the histological specimen. Unfortunately as this patient expired, no follow-up endoscopy could be performed to assess healing or to better visualize the underlying esophageal varices. Contributed by VC Kuo* and HE Nazario† *Methodist Dallas Medical Center, Department of Gastroenterology, Dallas, Texas and †Methodist Dallas Medical Center, The Liver Institute, Department of Transplant Hepatology and Gastroenterology, Dallas, Texas
Journal of Gastroenterology and Hepatology 30 (2015) 5 © 2014 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
5
Copyright of Journal of Gastroenterology & Hepatology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
doi:10.1111/jgh.12827
E D U C AT I O N A N D I M A G I N G
Hepatology: Esophageal bullae and hemorrhage in portal hypertension
Figure 1
Esophageal hemorhagic bullae on upper endoscopy.
A 60-year-old man presented with altered mental status and lethargy. He had a liver transplant 22 years ago due to cryptogenic cirrhosis with recurrence of cirrhosis in his allograft. The patient reported having dark stools and coffee ground like emesis. On admission, the patient was hypotensive with anemia, metabolic acidosis and acute kidney injury. The patient was started on octreotide and a proton pump inhibitor. On endoscopy, there were diffuse hemorrhagic bullae with ulceration in the esophagus (Figure 1). With gentle pressure to the bullae, there would be minor oozing of blood. No endoscopic intervention was performed. The patient expired within 36 hours of admission from multi-organ failure. An autopsy revealed diffuse patches of blood that elevated the mucosa. The tissue was extremely friable and would disintegrate upon removal. Histological examination of the esophagus revealed numerous subepithelial hemorrhages that elevated the squamous epithelium with dilated veins in the submucosa (Figure 2). The intact squamous epithelium did not reveal any evidence of acute inflammation, viral change, bacteria, or fungi. There was no underlying vasculitis or granulomatous inflammation. The subepithelial vascular lakes were most likely a result of esophageal varices with rupture and significant upper gastrointestinal hemorrhage. Gastroesophageal varices are a result of portal hypertension and the formation of portosystemic collaterals. They can seen in about 50% of patients with cirrhosis. Cirrhotic patients with varices will
Figure 2
Subepithelial hemorrhage on histology (H&E stain).
have an elevated hepatic venous pressure gradient of at least 10-12 mmHg. Esophagogastroduodenoscopy has remained the main modality for diagnosing varices in a cirrhotic patient. They can be classified into 3 sizes; small, medium and large. Small varices generally completely flatten with air insufflation. Medium and large varices are more tortuous and full and are distinguished by how much of the esophageal lumen they occupy. It has been recommended that all patients with a new diagnosis of cirrhosis have an upper endoscopy to screen for varices. The management of esophageal varices can be endoscopic, pharmacologic, or radiologic. This case presents a unique endoscopic presentation of a significant esophageal variceal bleed. The hemorrhagic bullae represented pools of blood that were trapped under the squamous epithelium of the esophagus as confirmed by the histological specimen. Unfortunately as this patient expired, no follow-up endoscopy could be performed to assess healing or to better visualize the underlying esophageal varices. Contributed by VC Kuo* and HE Nazario† *Methodist Dallas Medical Center, Department of Gastroenterology, Dallas, Texas and †Methodist Dallas Medical Center, The Liver Institute, Department of Transplant Hepatology and Gastroenterology, Dallas, Texas
Journal of Gastroenterology and Hepatology 30 (2015) 5 © 2014 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
5
Copyright of Journal of Gastroenterology & Hepatology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
