Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis

Table 1 Differential diagnosis of acute upper gastrointestinal bleeding in an alcoholic with advanced liver disease

Bleeding lesion	Endoscopic appearance	Pathophysiology	Nonsurgical treatment	Ref.
Etiologies related to portal hypertension
Esophageal varices	Serpiginous, bluish-grey, vessels protruding from the mucosa into the lumen that typically are largest just above the gastroesophageal junction	Varices provide a conduit for venous blood blocked from traversing through the liver because of cirrhosis to return to the heart	Endoscopy: variceal banding, variceal sclerotherapy	Garcia-Tsao et al[13], Beppu et al[14]
			Angiography: TIPS
			Other: balloon tamponade, octreotide
Gastric varices	Serpiginous, bluish-grey, vessels protruding from the mucosa into the lumen that are most commonly located in the gastric cardia, fundus or body	Varices provide a conduit for venous blood blocked from traversing through the liver because of cirrhosis to return to the heart	Angiography: TIPS Other: balloon tamponade, octreotide Endoscopy: cyanoacrylate injection therapy	Garcia-Pagán et al[15]
		Formation of gastric varices may be promoted by endoscopic obliteration of esophageal varices
Duodenal varices	Resemble esophageal varices in endoscopic appearance, but are located within duodenum	Rare site of varices which may be promoted by prior esophageal variceal banding or sclerotherapy and prior duodenal surgery	Endoscopy: variceal banding or sclerotherapy	Copelan et al[16], Matsui et al[17]
			Angiography:
			TIPS, angiographic occlusion therapy by embolization or balloon occlusion
Portal hypertensive gastropathy	Mosaic or snake-skin appearance of gastric mucosa, especially of the gastric fundus and proximal gastric body, due to dilated, ectatic, superficial mucosal vessels	Network of microcirculation that drains venous blood blocked from passing through the cirrhotic liver to return to the left atrium	TIPS	Patwardhan et al[18], Thuluvath et al[19]
Etiologies possibly related to portal hypertension
Gastric antral vascular ectasia	Intensely erythematous streaks on longitudinal folds oriented towards the pylorus in the antrum	May be related to stretch of antral vessels from duodenal bulb prolapse. Vascular engorgement from portal hypertension or from hormonal abnormalities (e.g., hyperestrogenemia with cirrhosis) may also contribute to lesion pathogenesis	Endoscopic therapy: APC, thermocoagulation, electrocoagulation, or radiofrequency ablation.	McGorisk et al[20], Payen et al[21]
Etiologies possibly related to alcoholism or advanced liver disease
Peptic ulcer disease	Focal ulcer: (depressed) crater covered by mucopurulent material	Major causes in general population include H. pylori infection or NSAID use. Idiopathic PUD is increasingly noted. Gastric infections or gastric malignancy may mimic PUD. Pathogenesis of PUD in ALD and cirrhosis discussed in text	Endoscopic therapy: discussed in text	Siringo et al[22], Vergara et al[23], Kamalaporn et al[24], D’Amico et al[25]
Mallory- Weiss tear	Longitudinally oriented erythematous tear or crack in the mucosa that straddles the gastroesophageal junction	Laceration due to mucosal trauma from retching or vomiting. Frequently associated with binge drinking or chronic alcoholism	Endoscopic therapy: discussed in text	Paquet et al[26], Schuman et al[27], Jensen et al[28]
Dieulafoy’s lesion	Elevated, pigmented spot that projects into the lumen from the mucosal surface without surrounding ulceration	Caliber-persistent artery near mucosal surface can erupt through thin overlying mucosal cells and cause bleeding	Endoscopic therapy: injection therapy, band ligation, electrocoagulation, APC	Cappell[29], Jeon et al[30], Nojkov et al[31]
			Angiography: local embolization
			Surgery: wedge resection

TIPS: Transjugular intrahepatic portosystemic shunt; APC: Argon plasma coagulation; PUD: Peptic ulcer disease; H. pylori: Helicobacter pylori; ALD: Alcoholic liver disease; NSAID: Nonsteroidal anti-inflammatory drug.