Observational Study
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World J Gastroenterol. Oct 14, 2014; 20(38): 13993-13998
Published online Oct 14, 2014. doi: 10.3748/wjg.v20.i38.13993
Epistaxis in end stage liver disease masquerading as severe upper gastrointestinal hemorrhage
Marine Camus, Dennis M Jensen, Jason D Matthews, Gordon V Ohning, Thomas O Kovacs, Rome Jutabha, Kevin A Ghassemi, Gustavo A Machicado, Gareth S Dulai
Marine Camus, Dennis M Jensen, Gordon V Ohning, Thomas O Kovacs, Rome Jutabha, Kevin A Ghassemi, Gustavo A Machicado, Gareth S Dulai, CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA 90095, United States
Marine Camus, Dennis M Jensen, Thomas O Kovacs, Rome Jutabha, Kevin A Ghassemi, Gustavo A Machicado, Gareth S Dulai, Division of Digestive Diseases at University of California, Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA 90095, United States
Marine Camus, University Paris 7, Department of Gastroenterology, Lariboisiere Hospital, APHP, Paris 75010, France
Dennis M Jensen, Gordon V Ohning, Thomas O Kovacs, Gustavo A Machicado, Gareth S Dulai, Gastroenterology Division at VA Greater Los Angeles Healthcare System, Los Angeles, CA 90095, United States
Jason D Matthews, Hunterdon Gastrointestinal Associates, Flemington, NJ 08822, United States
Author contributions: Jensen DM and Matthews JD designed research; Ohning GV, Kovacs TO, Jutabha R, Ghassemi KA, Machicado GA and Dulai GS performed research; Camus M contributed new reagents/analytic tools; Camus M and Jensen DM analyzed data; Camus M, Matthews JD and Jensen DM wrote the paper.
Supported by National Institutes of Health, No. 41301; Veteran Administration Clinical Merit Review Grant, to Dr Dennis M Jensen; and Philippe Foundation Grant, to Dr. Marine Camus
Correspondence to: Marine Camus, MD, Assistant Professor, Department of Gastroenterology, Lariboisiere Hospital, APHP, 2 rue Ambroise Pare, 75010 Paris, France. marine.camus@gmail.com
Telephone: +33-6-81933140 Fax: +33-1-49952577
Received: April 9, 2014
Revised: June 8, 2014
Accepted: July 11, 2014
Published online: October 14, 2014
Abstract

AIM: To describe the prevalence, diagnosis, treatment, and outcomes of end stage liver disease (ESLD) patients with severe epistaxis thought to be severe upper gastrointestinal hemorrhage (UGIH).

METHODS: This observational single center study included all consecutive patients with ESLD and epistaxis identified from consecutive subjects hospitalized with suspected UGIH and prospectively enrolled in our databases of severe UGIH between 1998 and 2011.

RESULTS: A total of 1249 patients were registered for severe UGIH in the data basis, 461 (36.9%) were cirrhotics. Epistaxis rather than UGIH was the bleeding source in 20 patients. All patients had severe coagulopathy. Epistaxis was initially controlled in all cases. Fifteen (75%) subjects required posterior nasal packing and 2 (10%) embolization in addition to correction of coagulopathy. Five (25%) patients died in the hospital, 12 (60%) received orthotopic liver transplantation (OLT), and 3 (15%) were discharged without OLT. The mortality rate was 63% in patients without OLT.

CONCLUSION: Severe epistaxis in patients with ESLD is (1) a diagnosis of exclusion that requires upper endoscopy to exclude severe UGIH; and (2) associated with a high mortality rate in patients not receiving OLT.

Keywords: Epistaxis, Upper gastrointestinal bleeding, End stage liver disease, Cirrhosis, Nasogastric tube, Liver transplantation, Digestive bleeding, Nasal packing, Coagulopathy

Core tip: Severe posterior nasopharyngeal epistaxis in hospitalized patients with end stage liver disease (ESLD): (1) is a diagnosis of exclusion that requires upper endoscopy to rule out common causes of upper gastrointestinal hemorrhage (UGIH); (2) can usually be effectively treated with nasal packing and correction of coagulopathy; (3) was the diagnosis of the bleeding source in 4.3 % of cirrhotic patients with a suspected UGIH; and (4) is associated with a high rate of mortality (63%) in those not receiving liver transplantation. Physicians managing patients with ESLD should be aware that epistaxis can masquerade as massive UGIH, particularly in those with severe coagulopathy.