Clinical evaluation

A. Variceal bleeding should be considered in any patient who presents with significant upper gastrointestinal bleeding. Signs of cirrhosis may include spider angiomas, palmar erythema, leukonychia, clubbing, parotid enlargement, and Dupuytren's contracture. Jaundice, lower extremity edema and ascites are indicative of decompensated liver disease.

B. The severity of the bleeding episode can be assessed on the basis of orthostatic changes (eg, resting tachycardia, postural hypotension), which indicates one-third or more of blood volume loss.

C. If the patient's sensorium is altered because of hepatic encephalopathy, the risk of aspiration mandates endotracheal intubation. Placement of a large-caliber nasogastric tube (22 F or 24 F) permits lavage for removal of blood and clots in preparation for endoscopy.

D. Nasogastric lavage should be performed with tap water, because saline may contribute to retention of sodium and water.

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