The nurse is assigned to a patient with chronic alcoholism and alcoholic cirrhosis. Examination of the patient is significant for dilated tortuous veins around his umbilicus and internal hemorrhoids. On the morning of his third day of the current admission, the patient acutely begins to vomit up large amounts of blood. Which describes the pathophysiology that most likely caused this event?

Question

The nurse is assigned to a patient with chronic alcoholism and alcoholic cirrhosis.  Examination of the patient is significant for dilated tortuous veins around his umbilicus and internal hemorrhoids.  On the morning of his third day of the current admission, the patient acutely begins to vomit up large amounts of blood.  Which describes the pathophysiology that most likely caused this event?

Accepted Answer

Rupture of esophageal varices. This patient with alcoholic liver cirrhosis presents with several signs and symptoms of portal hypertension, namely dilated veins around his umbilicus (caput medusae) and internal hemorrhoids.  Esophageal varices are a common finding of portal hypertension and rupture can result in sudden and significant hematochezia.  Alcoholic gastritis can result in an upper GI bleed but usually does not have such an acute presentation.  Rupture of the esophagus secondary to forceful vomiting (Boerhaave syndrome) is unlikely since the patient was not vomiting immediately before the bleeding started.  A Dieulafoy lesion is a vascular malformation of the stomach wall that commonly occurs secondary to chronic alcoholic gastritis and is prone to rupture resulting in copious bleeding.  However, this is far less likely than a variceal rupture in a patient with portal hypertension.

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