## Distinguishing Variceal vs Non-Variceal Bleeding in Cirrhosis ### Key Endoscopic Features **Key Point:** The presence of a visible vessel (red wale sign) or adherent clot within a varix is pathognomonic for variceal bleeding and is the single best discriminator between variceal and non-variceal sources. ### Comparison Table | Feature | Variceal Bleeding | Portal Hypertensive Gastropathy | | --- | --- | --- | | **Endoscopic appearance** | Blue/purple tortuous veins; may have visible vessel, red wale, or adherent clot | Diffuse antral mucosal erythema; reticular or mosaic pattern | | **Bleeding pattern** | Sudden, brisk; often massive | Slow, chronic; oozing | | **Visible vessel/clot** | Present in active/recent bleeding | Absent | | **Prevalence in cirrhosis** | ~50% of variceal patients bleed | Present in ~30% of cirrhotics; bleeds in ~5% | | **Prognosis** | High mortality if untreated | Better prognosis | ### Why This Discriminates **High-Yield:** Portal hypertensive gastropathy is a diffuse mucosal process that does NOT produce discrete varices with visible vessels. The presence of a visible vessel or clot is diagnostic of variceal bleeding and cannot occur in gastropathy. **Clinical Pearl:** Even when both lesions coexist (which is common in advanced cirrhosis), endoscopic identification of a visible vessel or clot in a varix confirms that lesion as the bleeding source and guides therapy (variceal ligation or sclerotherapy). ### Management Implications 1. Variceal bleeding → urgent variceal ligation/sclerotherapy + octreotide 2. Gastropathy → supportive care, PPI, beta-blockers; no endoscopic intervention [cite:Harrison 21e Ch 297]
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