Gastrointestinal varices differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Non-bleeding varices are asymptomatic. Ruptured esophageal and gastric varices may lead to upper gastrointestinal bleeding and present with hematemesis. They must be differentiated from other causes of upper gastrointestinal bleeding such as peptic ulcer disease, esophagitis, gastritis, angiodysplasia, Dieulafoy's lesion, vascular ectasia, Mallory-Weiss tears, aorto-enteric fistulas and upper gastrointestinal tumors.

Differentiating Gastrointestinal Varices From Other Diseases

Differentials of ruptured varices

Ruptured esophageal and gastric varices may lead to upper gastrointestinal bleeding and present with hematemesis. It must be differentiated from other causes of upper gastrointestinal bleeding. The following table outlines the differentials:

The following table summarizes the various causes of Upper gastrointestinal bleeding

Disease/Cause	Bleeding manifestations				Symptoms				Risk factors	Endoscopic findings
	Hematemesis	Melena	Hematochezia	Occult blood	Abdominal pain	Dysphagia	Dyspepsia	Weighloss
Ulcerative or erosive
Peptic ulcer disease	+	+	+	+	+	-	+	+/-	NSAIDs Infections: Helicobacter pylori CMV HSV Stress ulcer ZES	Ulcer with smooth, regular, rounded edges Ulcer base often filled with exudate Examination of the ulcer may reveal: Active bleeding Nonbleeding visible vessel Adherent clot Flat pigmented spot Clean ulcer base
Esophagitis	+	+	-	+	-	+	-	-	Gastroesophageal reflux disease Medications: Tetracycline Doxycycline Clindamycin Trimethoprim-sulfamethoxazole NSAIDs Bisphosphonates Potassium chloride Quinidine Iron supplements  Infections: HSV CMV Candida albicans HIV	Peptic esophagitis The ulcerations are usually irregularly shaped or linear, multiple, and distal. Pill-induced Ulcerations are usually singular and deep, occurring at points of stasis (especially near the carina), with sparing of the distal esophagus Infectious esophagitis: HSV – Discrete, superficial ulcers, with well-demarcated borders that tend to involve the upper or mid-esophagus; vesicles may be seen CMV – Ulcers range from small and shallow to large (>1 cm) and deep; most patients have multiple lesions Candida – Diffuse white plaques HIV – Tends to involve the mid to distal esophagus, ulcers may be shallow or deep, and may be large
Gastritis/gastropathy	+	+	-	+	+	-	+	-	Risk factors: H. pylori NSAIDs Excessive alcohol consumption Radiation injury Physiologic stress Weight loss surgery Bile reflux Risk factors for bleeding: Anticoagulant use	Erythematous mucosa Superficial erosions Nodularity Diffuse oozing
Complications of portal hypertension
Esophagogastric varices	+	+	+	-	+	-	-	-	Portal hypertension from: Cirrhosis Portal vein thrombosis	Vascular structures that protrude into the esophageal and/or gastric lumen Findings associated with an increased risk of hemorrhage: Longitudinal red streaks on the varices (red wale marks) Cherry-colored spots that are flat and overlie varices Raised, discrete red spots
Ectopic varices	+	+	+	-	-	-	-	-		Vascular structures that protrude into areas of the gastrointestinal tract lumen other than the esophagus or stomach (eg, small bowel, rectum)
Portal hypertensive gastropathy	+	+	+	+	+	-	-	-		Mosaic-like pattern that gives the gastric mucosa a "snakeskin" appearance
Vascular lesions
Angiodysplasia	+	+	+	+	-	-	-	-	End-stage renal disease Aortic stenosis Hereditary hemorrhagic telangiectasia Von Willebrand disease Radiation therapy	Small (5 to 10 mm), flat, cherry-red lesions, often with a fern-like pattern of arborizing, ectatic blood vessels radiating from a central vessel.
Dieulafoy's lesion	+	+	+	-	+	-	-	-	Bleeding may be associated with NSAIDs use Hypertension Chronic kidney disease Diabetes Alcohol abuse	Usually located in the proximal stomach May have active arterial spurting from the mucosa without an associated ulcer or mass If the bleeding has stopped, there may be a raised nipple or visible vessel without an associated ulcer
Gastric antral vascular ectasia	+	+	+	+	+	-	-	-	Cirrhosis with portal hypertension Chronic kidney disease Diabetes mellitus Scleroderma Bone marrow transplantation	Longitudinal rows of flat, reddish stripes radiating from the pylorus into the antrum.
Traumatic or iatrogenic
Mallory-Weiss syndrome	+	+	+	-	-	-	-	-	Vomiting/retching (often related to alcohol consumption) Straining at stool or lifting Coughing Seizures Blunt abdominal trauma Hiatal hernia	Tear in the esophagogastric junction. Usually singular and longitudinal, but may be multiple. The tear may be covered by an adherent clot.
Foreign body ingestion	+	+	+	+	-	+	-	-	Psychiatric disorders Dementia Loose dentures	Visualization of the foreign body endoscopically.
Post-surgical anastomotic hemorrhage (marginal ulcers)	+	+	+	+	+	-	+	-	Gastric bypass surgery NSAID use H. pylori infection Smoking	Ulceration/friable mucosa at an anastomotic site.
Aortoenteric fistula	+	+	+	-	+	-	-	-	Infectious aortitis Prosthetic aortic graft Atherosclerotic aortic aneurysm Penetrating ulcers Tumor invasion Trauma Radiation injury Foreign body perforation	Endoscopy may reveal a graft, an ulcer or erosion at the site Adherent clot, or an extrinsic pulsatile mass in the distal duodenum or esophagus.
Tumors
Upper GI tumors	+	+	+	+	+	+	+	+	History of alcoholism, smoking	Ulcerated mass in the esophagus, stomach, or duodenum. In gastric malignancies: The folds surrounding the ulcer crater may be nodular, clubbed, fused, or stop short of the ulcer margin The margins may be overhanging, irregular, or thickened Bleeding lymphoma may appear as An ulcerated mass Polypoid lesion As a gastric ulcer
Miscellaneous
Hemobilia	+	+	+	-	+	-	-	-	History of: Cholecystectomy Endoscopic biliary biopsies or stenting TIPS placement Angioembolization Blunt or penetrating abdominal trauma Gallstones Cholecystitis Hepatic or bile duct tumors Intrahepatic stents Hepatic artery aneurysms Hepatic abscesses	Blood or clot emanating from the ampulla. ERCP may reveal a filling defect in the bile duct
Hemosuccus pancreaticus	+	+	+	-	+	-	+	-	Chronic pancreatitis Pancreatic pseudocysts Pancreatic tumors Pancreatic pseudoaneurysm Therapeutic endoscopy of the pancreas or pancreatic duct: Pancreatic stone removal Pancreatic duct sphincterotomy Pseudocyst drainage Pancreatic duct stenting	Blood or clot emanating from the ampulla. Cross-sectional imaging or angiography is often required to confirm the diagnosis.