Date:
Patient:
MRN:
Clincian: (Gastroenterologist, Hepatologist)
Reason for Visit:
Follow-up for gastroesophageal varices (GEV)
Evaluation of symptoms and signs of bleeding
Review of imaging results
Discussion of treatment plan
History of Present Illness:
Briefly describe the patient’s current status:
Underlying liver disease causing portal hypertension (e.g., cirrhosis, chronic hepatitis)
Presence and severity of any symptoms suggestive of bleeding (hematemesis – vomiting blood, melena – black stools)
History of previous GEV bleeding episodes
Past Medical History:
Underlying cause of liver disease
History of upper GI bleeding (if any)
Family History:
Family history of liver disease (may be relevant depending on the underlying cause)
Social History:
Alcohol use (significant risk factor for liver disease)
Physical Exam:
Vital Signs: May be normal or abnormal depending on the severity of bleeding and presence of complications.
Signs of chronic liver disease (jaundice, ascites – fluid accumulation in the abdomen).
Abdominal: Splenomegaly (enlarged spleen).
Rectal exam: May reveal melena (if recent bleeding has occurred).
Labs:
Liver function tests (LFTs): Abnormal findings suggestive of underlying liver disease.
Complete Blood Count (CBC) – to assess for anemia (common in chronic liver disease and bleeding).
Coagulation studies (PT, INR) – may be abnormal in patients with liver disease and can worsen bleeding.
Consider mentioning other labs ordered as needed based on suspicion of other conditions.
Imaging:
Endoscopy (upper endoscopy with esophageal variceal bands): Gold standard for diagnosis and allows visualization of varices, their size, and signs of bleeding.
Esophagram – X-ray of the esophagus with contrast to evaluate for varices (less commonly used now).
Assessment:
Summarize the diagnosis and current status:
Confirmation of GEV diagnosis based on endoscopy or other imaging.
Size and grade of varices (based on endoscopic classification systems).
Presence of active bleeding or signs of recent bleeding.
Severity of underlying liver disease.
Plan:
Outline the treatment plan based on the assessment:
Management of underlying liver disease: Treating the cause of portal hypertension whenever possible.
Primary prophylaxis to prevent first variceal bleeding:
Endoscopic variceal band ligation (EVL) – most common approach, involves placing rubber bands on varices to reduce blood flow.
Beta-blockers – medications to reduce portal pressure.
Secondary prophylaxis to prevent re-bleeding after an episode:
Combination of endoscopic therapy (EVL) and medical therapy (beta-blockers, sometimes with additional medications like vasopressin analogs).
Transjugular intrahepatic portosystemic shunt (TIPS) creation – a procedure to create an alternative pathway for blood flow, considered in specific situations.
Prognosis:
Briefly discuss the prognosis. The prognosis depends on the severity of underlying liver disease and success of treatment in preventing bleeding.
GEV bleeding is a life-threatening complication, and early diagnosis and treatment are crucial.
Regular follow-up with a healthcare professional is essential to monitor varices and manage the underlying liver disease.
Education:
Document any education provided to the patient regarding:
The nature of GEV, their formation, and risk of bleeding
The importance of adherence to medications and regular follow-up endoscopies
Warning signs of bleeding and the need for immediate medical attention
The limitations of treatment and potential complications (e.g., post-banding ulcers)
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about treatment options and long-term management.
Consider mentioning the importance of avoiding medications that can worsen portal hypertension (e.g., NSAIDs).
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a gastroenterologist or hepatologist for diagnosis, treatment recommendations, and prognosis.