A 48-year-old woman with decompensated cirrhosis due to hepatitis C develops ascites. On examination, she has abdominal distension and shifting dullness. What is the most common site of variceal bleeding in patients with portal hypertension?

Explanation

## Most Common Site of Variceal Bleeding in Portal Hypertension **Key Point:** Esophageal varices account for ~70–80% of all variceal bleeding in portal hypertension. They develop at the gastroesophageal junction due to the unique anatomy of the left gastric vein and esophageal venous drainage. ### Anatomical Basis The esophagus has a rich venous plexus that drains via the esophageal veins into the azygos system (systemic circulation). However, the distal esophagus and gastroesophageal junction receive drainage from the left gastric vein (coronary vein), which is a direct tributary of the portal vein. When portal pressure rises: 1. Blood preferentially shunts through the left gastric vein 2. Esophageal submucosal veins dilate and form varices 3. The thin esophageal mucosa offers minimal support → high rupture risk 4. Mechanical trauma from food/swallowing precipitates bleeding ### Frequency of Variceal Bleeding by Site | Site | Frequency | Mortality if Bleeding | Clinical Notes | |---|---|---|---| | **Esophageal** | 70–80% | 15–20% | Most common; highest rupture risk | | **Gastric** | 10–20% | 25–35% | Higher mortality; harder to treat | | **Rectal** | 2–5% | Variable | Rare; associated with portal colopathy | | **Duodenal** | <1% | High | Very rare; often missed on endoscopy | **Clinical Pearl:** Gastric varices, though less common, have a higher mortality rate (25–35%) because they are often larger, bleed more profusely, and are technically more difficult to treat with endoscopic ligation. They occur at the gastroesophageal junction (GOV type 1) or in the gastric fundus (GOV type 2, IGV). **High-Yield:** The **Paix classification** divides gastric varices into: - **GOV1** (gastroesophageal varices type 1): extend along lesser curve → 70% of gastric varices - **GOV2** (gastroesophageal varices type 2): fundal extension → higher bleeding risk - **IGV** (isolated gastric varices): fundus only → rare **Mnemonic:** **"EGD for varices"** — **E**sophageal (most common), **G**astric (second), **D**uodenal (rare). This reflects the frequency of variceal bleeding sites. [cite:Harrison 21e Ch 297]