Melena

Sanchez, Sandoval, Santiago M, Santiago S, Santiago V, Santos A, Santos E, Santos K, Santos P, Sarile, Savella, Sebollena

1
 1. History of present Illness
2. Review of Systems
Subjective Data 3. Patient History

2
History of Present Illness

3
 Santos, Paula Patrice D,

51 yo Male, Barangay Tanod

Chief Complaint: Black stools

intermittent back pain graded

6/10,
Whole abdominal ultrasound persistence of melena
liver cirrhotic changes, thickened gallbladder wall (+) pale and weak
likely due to hypoalbuminemia and ascites;
calcified cyst, left kidney; slightly prominent
splenomegaly; minimal abdominal pelvic ascites.
liveraide capsule compliant
4 Months PTA 2 Months PTA
Persistence
3 Months PTA Persistence of dark colored stools,
intermittent back hematemesis (1 cup) EGD
pain (3/10), ADMISSION and EGD ADMISSION
(-) nausea, vomiting , esophageal varices s/p rubber band ligation x7
(3/18/19)
fever. omeprazole 40mg tab od,
propranolol 40 mg tab od,
lactulose 30cc; NC.
4
 Santos, Paula Patrice D,

51 yo Male, Barangay Tanod

Chief Complaint: Black stools E
R I T IQU
C

5
 Santos, Paula Patrice D,

51 yo Male, Barangay Tanod

Chief Complaint: Black stools
episodic passing of small
amount (half a teaspoon) of dark
tarry stools, prog. Increase
(-) abdominal pain
whole abdominal ultrasound
liver cirrhotic changes, slightly prominent
splenomegaly; minimal abdominal pelvic ascites. 2 Months PTA unable to perform
Silymarin (liveraide) 1cap t.i.d. previous work as
compliant barangay tanod

black tarry stools,

Vomited fresh blood (2 cup)
3 Months PTA (+) dizziness, body malaise, DOB
ADMISSION and EGD
esophageal varices s/p rubber band ligation x7
omeprazole 40mg tab od,
propranolol 40 mg tab od, lactulose
30cc. (Compliant until supplies last)
6
 Santos, Paula Patrice D,

51 yo Male, Barangay Tanod

Chief Complaint: Black stools

(+) pale, loss of appetite and

EGD
easily fatigued by minimal to
moderate activities ADMISSION

1 week PTA Hours PTA

4 days PTA (3/18/19)

increased amount of black
Recurred black tarry
tarry stools (1 cup),
stools minimal in amount
(+) dizziness and DOB
(1 teaspoon per episode)
noted every day

7
Review of Systems

8
 Sanchez, Joana Camille S.

Review of Systems
General Survey (-) malaise, (-) jaundice

Cutaneous (-) pruritus, (-) rash

Eyes (-) dryness, (-) blurring of vision, (-) diplopia, (-)

photophobia, (-) burning sensation, (-) itchiness

Ears (-) discharge, (-) tinnitus, (-) otalgia, (-) dizziness

Nose (-) epistaxis, (-) congestion

Throat and Mouth (-) limitation of motion, (-) sensation of lump in the
throat, (-) dysgeusia, (-) dry mouth,

Respiratory (*) dyspnea, (-) cough, (-) colds, (-) hemoptysis, (-)
wheezing, (-) night sweats

9
 Sanchez, Joana Camille S.

Review of Systems
Cardiovascular (-) chest pain, (-) paroxysmal nocturnal dyspnea

Endocrine (-) cold or hot intolerance, (-) polydipsia, (-) polyuria,

(-) polyphagia

Genitourinary (-) dysuria, (-) oliguria, (-) hematuria, (-) frequency, (-)
urinary retention

Muskuloskeletal (-) joint pains, (-) limitation in movement

Hematologic (-) easy bruising, (-) gingival bleeding

Neurologic (-) headache, (-) loss of consciousness, (-)

convulsions

10
Patient History

11
 Sanchez, Joana Camille S.

Past Medical History

1 (-) HPN, DM, Thyroid Problem, Asthma, Cancer

Previous Hospitalizations: Upper GI bleeding secondary to

bleeding esophageal varices s/p rubber band ligation ×7 (USTH,
January 2-8, 2019)
Blood Transfusions: 3 units of pRBC (USTH, January 2-8, 2019)
Allergies: None
Current Medications: Silimarin (Liveraide) capsules

Family History Personal and Social History

3
2 Non smoker, Denies illicit drug
(-) Hypertension, DM,
use
Cancer
MI, Stroke, Thyroid, TB Alcohol drinker - 3 bottles of
500 mL beer 3 times a week
(disc. last November 2018) 12
 Sanchez, Joana Camille S.

Past Medical History

1 (-) HPN, DM, Thyroid Problem, Asthma, Cancer

Previous Hospitalizations: Upper GI bleeding secondary to bleeding esophageal

varices s/p rubber band ligation ×7 (USTH, January 2-8, 2019)
Blood Transfusions: 3 units of pRBC (USTH, January 2-8, 2019)
-Complications? No complications noted
Allergies: None
Current Medications: Silimarin (Liveraide) capsules
-Dosage and frequency? 1 capsule tid

Family History Personal and Social History

2 (-) Hypertension, DM, Cancer 3 Non smoker, Denies illicit drug use
-Second hand smoke? (+) second
MI, Stroke, Thyroid, TB hand smoke in work
Alcohol drinker - 3 bottles of 500 mL beer
3 times a week (disc. last November
2018)
-Age started? 16 13
 Sanchez, Joana Camille S.

Current Health Status/Risk Factors

4 -Nutrition/dietary habits: fish and vegetables, occasional
oily foods
-Sleep pattern: regular, 6-8 hrs of sleep
-Immunizations: complete

14
Q&A

15
 1. Physical Exam

Objective Data 2.
3.
Pertinents
Organ Systems

16
Physical Examination
Santiago, Selwyn Joseph C.

17
 Santiago, Selwyn Joseph C.

Physical Examination
Admission: Actual PE:

General Survey: General Survey:

- Conscious - Conscious
- Coherent - Coherent
- Ambulatory - Ambulatory
- Not in cardiorespiratory distress - Not in cardiorespiratory distress

18
 Santiago, Selwyn Joseph C.

Physical Examination
Admission: Actual PE:
Vital Signs Vital Signs
- BP: 90/60 mmHg - BP: 120/60 mmHg
- PR: 88 bpm - PR: 89 bpm
- RR: 17cpm, regular - RR: 20 cpm, regular
- Temperature: 36.5 ºC - Temperature: 37.4 ºC
- O2Sat: 99% - O2Sat: 93%

19
 Santiago, Selwyn Joseph C.

Physical Examination
Admission: Actual PE:

Skin: Skin:

- Pallor (+) - Pallor (+)

- Warm moist skin - Warm moist skin
- Good skin turgor - Good skin turgor
- No rashes - No rashes
- No cyanosis - No cyanosis
- Jaundice (-) - Jaundice (-)
- Palmar erythema (-) - Palmar erythema (-)

20
 Santiago, Selwyn Joseph C.

Physical Examination
Admission:
Actual PE:
Head:
Head:
- Well distributed hair
- Well distributed hair
- No lice
- No lice
- No nits
- No nits

21
 Santiago, Selwyn Joseph C.

Physical Examination
Admission: Actual PE:

Eyes Eyes

- Icteric Sclerae (-) - Icteric Sclerae (-)

- Pale palpebral conjunctiva - Pale palpebral conjunctiva
- Pupils 2-3mm ERTL - Pupils 2-3mm ERTL

22
 Santiago, Selwyn Joseph C.

Physical Examination
Admission: Actual PE:

Mouth/Oral Cavity: Mouth/Oral Cavity:

- Dry lips - Moist lips

- Moist buccal mucosa - Moist buccal mucosa
- No sores/ulcers - No sores/ulcers
- Non-hyperemic - Non-hyperemic
- Non-exudative posterior - Non-exudative posterior pharyngeal
pharyngeal wall wall

23
 Santiago, Selwyn Joseph C.

Physical Examination
Admission: Actual PE:

Neck: Neck:

- No limitation of movement - No limitation of movement

- Neck veins not distended - Neck veins not distended
- Thyroid gland not enlarged - Thyroid gland not enlarged
- No cervical lymphadenopathy - No cervical lymphadenopathy

24
 Santiago, Selwyn Joseph C.

Physical Examination
Admission: Actual PE:

Ears Ears

- Aural discharge (-) - Aural discharge (-)

- Tragal Tenderness (-) - Tragal Tenderness (-)

25
 Santiago, Selwyn Joseph C.

Physical Examination
Admission: Actual PE:

Lungs: Lungs:

- Symmetrical chest expansion - Symmetrical chest expansion

- Equal tactile and vocal fremitus - Equal tactile and vocal fremitus
- Resonant on all lung fields - Resonant on all lung fields
- Clear breath sounds - Clear breath sounds

26
 Santiago, Selwyn Joseph C.

Physical Examination
Admission: Actual PE:

Heart: Heart:

- Adynamic precordium - Adynamic precordium

- Apex beat at 5th LICS MCL, not - Apex beat at 5th LICS MCL, not
sustained, nor diffused, no heaves, sustained, nor diffused, no heaves,
lifts, thrills lifts, thrills
- JVP: 3 cm at 30

27
 Santiago, Selwyn Joseph C.

Physical Examination
Admission: Actual PE:

Gastrointestinal: Gastrointestinal:

- Globular - Globular
- Soft
- Soft - Slightly distended
- Slightly distended - RUQ tenderness (+)
- Rebound tenderness (-)
- RUQ tenderness (+)
- Normoactive bowel sounds
- Rebound tenderness (-) - Tympanitic on all quadrants
- Normoactive bowel sounds - Shifting dullness (+)

- Tympanitic on all quadrants - (-) Caput medusae

- (-) Venous hum
28
 Santiago, Selwyn Joseph C.

Physical Examination
Admission: Actual PE:

Digital Rectal Exam: Digital Rectal Exam:

- Skin tags (-) - Not done

- Fissures (-)
- Tight sphincteric tone
- Hemorrhoids (-)
- Black tarry stools (+)

29
 Santiago, Selwyn Joseph C.

Physical Examination
Admission: Actual PE:

Extremities: Extremities:

- Pulses full and equal - Pulses full and equal

- No edema - No edema
- No cyanosis - No cyanosis
- No deformities - No deformities
- Clubbing (-) - Clubbing (-)
- Asterixis (-) - Asterixis (-)

30
Salient Features

31
 SANTIAGO, Maria Margarita S.

3 ORGAN SYSTEMS

Vascular Gastrointestinal Immunological

- UGIB secondary - UGIB - UGIB secondary to
to Portal/Splenic secondary to H. pylori
Vein Thrombosis portal
hypertension,
secondary to
liver cirrhosis
32
 SANTIAGO, Maria Margarita S.

Subjective Pertinent (+) Objective Pertinent (+)

51 years old Male BP: 90/60 RR: 17 cpm

(+) Pallor (+) Dyspnea PR: 88 bpm BMI: 25.8
Immunological (+) Dizziness (+) Dry lips (+) RUQ tenderness
- UGIB Loss of appetite *(+) Tarry stool
secondary Splenomegaly
to H. pylori *Esophageal varices

Subjective Pertinent (-) Objective Pertinent (-)

(-) Nausea Conscious, coherent, ambulatory

(-) Jaundice (-) Jaundice
(-) Palmar Erythema
(-) Icteric Sclerae
33
 SANTIAGO, Maria Margarita S.

Subjective Pertinent (+) Objective Pertinent (+)

51 years old Male BP: 90/60 RR: 17 cpm

(+) Pallor (+) Dyspnea PR: 88 bpm BMI: 25.8
Vascular (+) Dizziness (+) Dry lips (+) RUQ tenderness
- UGIB Loss of appetite (+) Tarry stool
secondary Splenomegaly
to *Esophageal varices
Portal/Splen
ic Vein Subjective Pertinent (-) Objective Pertinent (-)
Thrombosis
(-) Nausea Conscious, coherent, ambulatory
(-) Jaundice (-) Jaundice
(-) Palmar Erythema
(-) Icteric Sclerae
34
 SANTIAGO, Maria Margarita S.

Subjective Pertinent (+) Objective Pertinent (+)

51 years old Male BP: 90/60 RR: 17 cpm

(+) Pallor (+) Dyspnea PR: 88 bpm BMI: 25.8
Gastrointestinal (+) Dizziness (+) Dry lips (+) RUQ tenderness
- UGIB Loss of appetite (+) Tarry stool
secondary to Splenomegaly
portal *Esophageal varices
hypertension
, secondary Subjective Pertinent (-) Objective Pertinent (-)
to liver
(-) Nausea Conscious, coherent, ambulatory
cirrhosis
(-) Jaundice (-) Jaundice
(-) Palmar Erythema
(-) Icteric Sclerae
35
Pathophysiology

36
Liver Cirrhosis

37
 SANDOVAL, Mary Simonee A.

Liver Cirrhosis
● Fibrosis → regenerative nodules
● Results to:
○ Decrease hepatocellular mass and function
○ Alteration of blood flow

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles 38
of Internal Medicine (20th ed., p. 2405). New York: McGraw-Hill.
 SANDOVAL, Mary Simonee A.

Liver Cirrhosis
Cirrhosis
(Decompensated)

Loss of hepatocellular
Portal hypertension
function

Development of
ascites Jaundice

Bleeding from
esophageal varices Coagulation disorders

Hypoalbuminemia

Contribute to
Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. portosystemic
Hauser, & J. Loscalzo (Eds.), Harrison's Principles of Internal Medicine (20th ed., p. 2405). New York: encephalopathy 39
McGraw-Hill.
 SANDOVAL, Mary Simonee A.

Liver Cirrhosis

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles 40
of Internal Medicine (20th ed., p. 2405). New York: McGraw-Hill.
 SANDOVAL, Mary Simonee A.

Liver Cirrhosis

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles 41
of Internal Medicine (20th ed., p. 2405). New York: McGraw-Hill.
 SANDOVAL, Mary Simonee A.

Liver Cirrhosis

Chronic alcohol use Absence of

inflammation/necrosis

- centrilobular
Fibrosis - pericellular
- periportal

Disruption of normal Replacement of liver cells <3mm in diameter

liver architecture by regenerative nodules “micronodular”

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles 42
of Internal Medicine (20th ed., p. 2405). New York: McGraw-Hill.
 SANDOVAL, Mary Simonee A.

Liver Cirrhosis
Alcohol Oxidative damage to Connective tissue
hepatocyte membrane appears in periportal
and pericentral zones
Absorbed by small
Kupffer cell activation
intestine Connects portal triads
with central veins
Gastric alcohol Profibrogenic
dehydrogenase initiate cytokine production
alcohol metabolism Form regenerative
Stellate cell activation nodules
Form acetaldehyde
Production of excess Hepatocyte loss and
Formation of reactive collagen and ECM destruction
oxygen species

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles 43
of Internal Medicine (20th ed., p. 2405). New York: McGraw-Hill.
Complications of Cirrhosis:
Splenomegaly

44
 SANDOVAL, Mary Simonee A.

Splenomegaly
● Presence of an enlarged spleen
○ Obliteration of Traube’s space on PE
● Development of thrombocytopenia and leukopenia
● Splenomegaly with Thrombocytopenia
○ Common feature in patients with cirrhosis
○ First indication of portal hypertension

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles 45
of Internal Medicine (20th ed., p. 2405). New York: McGraw-Hill.
 SANDOVAL, Mary Simonee A.

Splenomegaly Fibrosis in Liver

Cirrhosis

Obstruction of blood
flow

Increase in splenic
blood flow

Congestion of spleen

Splenomegaly

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles 46
of Internal Medicine (20th ed., p. 2405). New York: McGraw-Hill.
Complications of Cirrhosis:
Ascites

47
 SANDOVAL, Mary Simonee A.

Ascites
● Accumulation of fluid within the peritoneal cavity
● Most common cause: portal hypertension due to cirrhosis

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles 48
of Internal Medicine (20th ed., p. 2405). New York: McGraw-Hill.
 SANDOVAL, Mary Simonee A.

Ascites Cirrhosis Due to vasodilators

such as Nitric Oxide

Increase in intrahepatic Vasodilation of splanchnic

resistance arterial system Causes underfilling of
Portal hypertension arterial circulation
Increased portal Increase in portal venous
pressure inflow

Increased production of
Sodium retention Activation of RAAS
splanchnic lymph

Fluid accumulation and

expansion of ECF volume

Ascites
Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles 49
of Internal Medicine (20th ed., p. 2405). New York: McGraw-Hill.
Complications of Cirrhosis:
Esophageal Varices

50
 SARILE, Criselda M.

Esophageal Varices
● Abnormally enlarged veins due to increased blood flow into smaller blood
vessels that aren’t designed to carry large volumes of blood
● Usually caused by portal hypertension

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles
of Internal Medicine (20th ed., p. 2405). New York: McGraw-Hill. 51
 SARILE, Criselda M.

Esophageal Varices
Cirrhosis

Increase in intrahepatic Vasodilation of splanchnic

Portal hypertension resistance arterial system

Increased portal
pressure

Ballooning of
esophageal vessels Increase blood flow
to smaller vessels
due to blockade
Esophageal Varices

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles
of Internal Medicine (20th ed., p. 2405). New York: McGraw-Hill. 52
Complications of Cirrhosis:
Hematemesis and Melena

53
 SARILE, Criselda M.

Hematemesis and Melena

● Hematemesis - vomitus of red blood or “coffee-grounds” material
● Melena - dark black, tarry, foul-smelling stool

● Common cause: indicative of upper gastrointestinal source of bleeding

54
 SARILE, Criselda M.

Melena
Cirrhosis

Portal hypertension
Increase in intrahepatic Vasodilation of splanchnic
resistance arterial system

Increase blood flow Increased portal

to smaller vessels pressure Further increase in
due to blockade pressure and the friability
of mucosa leads to rupture
Ballooning of Portal Hypertensive of the blood vessels
esophageal vessels Gastropathy

Upper gastrointestinal
Esophageal Varices Melena
bleeding

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles 55
of Internal Medicine (20th ed., p. 2405). New York: McGraw-Hill.
 SARILE, Criselda M.

Hematemesis
Cirrhosis

Portal hypertension
Increase in intrahepatic Vasodilation of splanchnic
resistance arterial system

Increase blood flow Increased portal

to smaller vessels pressure Further increase in
due to blockade pressure and the friability
of mucosa leads to rupture
Ballooning of Portal Hypertensive of the blood vessels
esophageal vessels Gastropathy

Upper gastrointestinal
Esophageal Varices Hematemesis
bleeding

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles 56
of Internal Medicine (20th ed., p. 2405). New York: McGraw-Hill.
57
 Diagnosis:
Upper Gastrointestinal Bleeding Secondary to Portal
Hypertension, Secondary to Liver Cirrhosis

58
Pathology
Santos, Elijah L.

59
 Santos, Elijah L.
Cirrhosis

60
61
Santos, Elijah L.

62
 Santos, Elijah L.
Hepatic Steatosis (Fatty Liver)

63
 Santos, Elijah L.
Alcoholic Steatohepatitis

64
 Santos, Elijah L.
Alcoholic Steatofibrosis

65
 Santos, Elijah L.
Esophageal Varices

66
 Laboratory
Santos, Anna Dominique

67
 Santos, Anna Dominique

Endoscopy
● Gold standard for upper GI bleeding
● Esophagogastroduodenoscopy
● Visually examine the upper digestive
system (including the esophagus, stomach
and duodenum)
● Also for used for treatment

Samuel, R. (2018). Evaluation and management of variceal and non-variceal upper gastrointestinal bleeding. Retrieved from 68
https://www.sciencedirect.com/science/article/pii/S0011502918300245?via%3Dihub on March 20, 2019.
 Santos, Anna Dominique

Liver Biopsy
● Gold standard for liver cirrhosis
● Assess the stage of liver fibrosis in
people with chronic liver disease
● Not popular with patients

National Guideline Centre (2016). Cirrhosis in Over 16s: Assessment and Management. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK385200/ On March 20, 2019. 69
 Santos, Anna Dominique

Routine Laboratory Liver Blood Tests

● Alanine Aminotransferase (ALT)
● Aspartate Aminotransferase (AST)
● Alkaline Phosphate (ALP)
● Total Bilirubin
● Albumin

National Guideline Centre (2016). Cirrhosis in Over 16s: Assessment and Management. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK385200/ On March 20, 2019. 70
 Santos, Anna Dominique

Liver Function Tests

Alanine Aminotransferase

- normally found largely in the liver

- released into the bloodstream as the result
of liver injury

Aspartate Aminotransferase

- normally found in a variety of tissues

including liver, heart, muscle, kidney, and
the brain

National Guideline Centre (2016). Cirrhosis in Over 16s: Assessment and Management. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK385200/ On March 20, 2019. 71
 Radiology
Sebollena, Kristina Maria C.

72
 Sebollena, Kristina Maria C.

NORMAL
ESOPHAGUS
BARIUM SWALLOW + CHEST
X-RAY - Right anterior oblique
view

3 Normal Indentations:

- Aortic Arch
- Left Atrium
- Left Main Bronchus

Francis, J. (2011) Normal Indentations of the Esophagus in Barium Swallow. Retrieved from
https://pgblazer.com/normal-indentations-on-the-esophagus-in-barium-swallow-right-anterior-oblique-view-chest-x-ray/ on March 19, 2019 73
 Sebollena, Kristina Maria C.

ESOPHAGEAL
MUCOSA
BARIUM SWALLOW + CHEST
X-RAY - Right anterior oblique
view

Normal mucosal folds are thin

and parallel

Demos, T.J., Posniak, H.V., Nagamine, W., and Olson, M., (2007) Radiology of the Esophagus Part I p. 345 - 348 74
 Sebollena, Kristina Maria C.
ESOPHAGEAL
VARICES
BARIUM SWALLOW +
CHEST X-RAY - Right
anterior oblique view

Serpiginous filling
defects are seen

Gore, R.M., Levine M.S. (2000) Textbook of Gastrointestinal Radiology. 2nd Ed. Philadelphia. P. 90-257, 316-509 75
 Sebollena, Kristina Maria C.

NORMAL LIVER
ULTRASOUND

Echogenicity is equal or
slightly greater than the
adjacent renal cortex
(rc)

Hamer, O.W., Aguirre, D.A., Casola, G., Lavine, J.E., Woenckhaus, M., Sirlin, C.B. (2006) Fatty Liver: Imaging Patterns and Pitfalls. Radio Graphics. Volume 26, Issue 6, p. 1637 - 1653 76
 Sebollena, Kristina Maria C.

NORMAL LIVER
CT SCAN

Homogenous

Attenuation of the Liver

is higher than that of the
Spleen

Hamer, O.W., Aguirre, D.A., Casola, G., Lavine, J.E., Woenckhaus, M., Sirlin, C.B. (2006) Fatty Liver: Imaging Patterns and Pitfalls. Radio Graphics. Volume 26, Issue 6, p. 1637 - 1653 77
 Sebollena, Kristina Maria C.

NORMAL LIVER
MRI SCAN

Hamer, O.W., Aguirre, D.A., Casola, G., Lavine, J.E., Woenckhaus, M., Sirlin, C.B. (2006) Fatty Liver: Imaging Patterns and Pitfalls. Radio Graphics. Volume 26, Issue 6, p. 1637 - 1653 78
 Sebollena, Kristina Maria C.

LIVER CIRRHOSIS
ULTRASOUND

Coarsened hepatic
echotexture

Hyperechogenicity of the
liver compared to the renal
cortex

Kreuer, S., Elguthun, M., & Tommack, M. (2016) Imaging Findings in Cirrhosis. J An Osteopath College of Radiology, vol 5 issue 2 79
 Sebollena, Kristina Maria C.

LIVER
CIRRHOSIS

CT SCAN

V - shaped area of subtle hypoattenuation (yellow

arrow)

Retraction of the hepatic contour (bold triangle)

Sangster, G., Previgliano, M. N., Chwoschtschinsky, E., Heldmann, M. G. (2013) MDCT Imaging Findings of Liver Cirrhosis: Spectrum of Hepatic and Extrahepatic Abdominal Complications. HPB Surgery.
80
Pandawi Publishing Co. p. 1 - 13
 Sebollena, Kristina Maria C.

LIVER
CIRRHOSIS
CT SCAN

Siderotic regenerative
nodules

Multiple high attenuation

hepatic nodules

Sangster, G., Previgliano, M. N., Chwoschtschinsky, E., Heldmann, M. G. (2013) MDCT Imaging Findings of Liver Cirrhosis: Spectrum of Hepatic and Extrahepatic Abdominal Complications. HPB
81
Surgery. Pandawi Publishing Co. p. 1 - 13
 Sebollena, Kristina Maria C.

LIVER
CIRRHOSIS
CT SCAN

Macronodular regenerative
nodules

Multiple nodular isodense

lesions

Liver margin is deformed

Sangster, G., Previgliano, M. N., Chwoschtschinsky, E., Heldmann, M. G. (2013) MDCT Imaging Findings of Liver Cirrhosis: Spectrum of Hepatic and Extrahepatic Abdominal Complications.
82
HPB Surgery. Pandawi Publishing Co. p. 1 - 13
 Sebollena, Kristina Maria C.

LIVER
CIRRHOSIS
CT SCAN

Hepatic artery enlargement

and tortuosity

“Cork-screw” Hepatic
arteries

Kreuer, S., Elguthun, M., & Tommack, M. (2016) Imaging Findings in Cirrhosis. J An Osteopath College of Radiology, vol 5 issue 2 83
 LIVER CIRRHOSIS
Sebollena, Kristina Maria C.

MRI SCAN

Kreuer, S., Elguthun, M., & Tommack, M. (2016) Imaging Findings in Cirrhosis. J An Osteopath College of Radiology, vol 5 issue 2 84
Pharmacology

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Goals of Treatment
● Treat cause of upper GI bleeding
● Prevention of ulcer rebleeding
● Prevention of complications

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 Savella, Alecza Mae C.

Pharmacologic Therapy

88
 Savella, Alecza Mae C.

Esophageal Bleeding

Efficacy Safety Suitability Cost Total

Antibiotics ++++ ++++ + ++++ 13

Ocreotide ++++ ++++ ++++ ++++ 16

Vasopressin ++++ ++++ ++++ +++ 15

Beta-blockers ++++ ++++ ++++ ++++ 16

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 Savella, Alecza Mae C.

Liver Cirrhosis

Efficacy Safety Suitability Cost Total

Corticosteroids ++ + ++ ++++ 8

Pentoxifylline ++++ ++++ ++++ + 13

Anti-TNF +++ + + + 6

Bergheim, I., Mcclain, C. J., & Arteel, G. E. (2005). Treatment of Alcoholic Liver Disease. Digestive Diseases, 23(3-4), 275-284. doi:10.1159/000090175 90
Nonpharmacologic Therapy

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 Santiago, Veronica Mae K.

Variceal Hemorrhage

Endoscopic variceal ligation Balloon tamponade (Sengstaken-Blakemore

Repeated variceal band ligation tube or Minnesota tube)

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles of Internal
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 Santiago, Veronica Mae K.

Variceal Hemorrhage
- Transvenous intrahepatic portosystemic shunt
- Surgical esophageal transection

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles of Internal 93
Medicine (20th ed., p. 2405). New York: McGraw-Hill.
 Santiago, Veronica Mae K.

Liver Cirrhosis
- Complete abstinence from alcohol
- Liver transplantation
- Good nutrition and long term medical supervision

Bacon, B. R. (2018). Cirrhosis and its complications. In J. Jameson, D. L. Kasper, D. L. Longo, A. S. Fauci, S. L.
Hauser, & J. Loscalzo (Eds.), Harrison's Principles of Internal Medicine (20th ed., p. 2405). New York:
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McGraw-Hill.
THANK YOU

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