Acute Variceal Bleeding - Searching For the Site of Bleeding

The major challenge for the endoscopist is to determine if the bleeding has been from esophageal, esophagogastric, or isolated gastric varices. In the absence of active bleeding or an obvious adherent or protruding clot, large distal esophageal varices (i.e., within 5 cm of the squamocolumnar junction) with red wale markings should be interpreted as the cause of bleeding. Endoscopic therapy should be initiated and directed at these varices. If the esophageal varices continue into the cardia, that is, are esophagogastric varices, endoscopic therapy should begin on the cardia side of the squamocolumnar junction because the gastric component of these varices usually can be eliminated. Once initiated, endoscopic therapy should most often be pursued with the eventual goal of eradication. After the initial treatment, endoscopic therapy is usually repeated in 5 to 7 days and then every 1 to 2 weeks until the distal esophageal varices are obliterated or reduced to a very small size. The interval between follow-up procedures tends to be longer (i.e., 2 weeks) in patients who have undergone variceal band ligation. Once eradicated, varices are typically reexamined in 6-month periods.