Management of Gastric Varices

Juan Carlos Garcia–Pagán; Marta Barrufet; Andres Cardenas; Àngels Escorsell

Disclosures

Clin Gastroenterol Hepatol. 2014;12(6):919-928. 

In This Article

Abstract and Introduction

Abstract

According to their location, gastric varices (GV) are classified as gastroesophageal varices and isolated gastric varices. This review will mainly focus on those GV located in the fundus of the stomach (isolated gastric varices 1 and gastroesophageal varices 2). The 1-year risk of GV bleeding has been reported to be around 10%–16%. Size of GV, presence of red signs, and the degree of liver dysfunction are independent predictors of bleeding. Limited data suggest that tissue adhesives, mainly cyanoacrylate (CA), may be effective and better than propranolol in preventing bleeding from GV. General management of acute GV bleeding must be similar to that of esophageal variceal bleeding, including prophylactic antibiotics, a careful replacement of volemia, and early administration of vasoactive drugs. Small sample–sized randomized controlled trials have shown that tissue adhesives are the therapy of choice for acute GV bleeding. In treatment failures, transjugular intrahepatic portosystemic shunt (TIPS) is considered the treatment of choice. After initial hemostasis, repeated sessions with CA injections along with nonselective beta-blockers are recommended as secondary prophylaxis; whether CA is superior to TIPS in this scenario is not completely clear. Balloonoccluded retrograde transvenous obliteration (BRTO) has been introduced as a new method to treat GV. BRTO is also effective and has the potential benefit of increasing portal hepatic blood flow and therefore may be an alternative for patients who may not tolerate TIPS. However, BRTO obliterates spontaneous portosystemic shunts, potentially aggravating portal hypertension and its related complications. The role of BRTO in the management of acute GV bleeding is promising but merits further evaluation.

Introduction

Prevalence of gastric varices (GV) in patients with cirrhosis is estimated to be near 17%. However, this estimation is based on only one study;[1] therefore, the actual magnitude of the problem is not well known. According to their location within the stomach, GV are classified as gastroesophageal varices (GOV) and isolated gastric varices (IGV). GOV are divided as GOV1, which are esophageal varices that extend below the gastroesophageal junction along the lesser curve of the stomach, and GOV2, which are those that extend beyond the gastroesophageal junction into the fundus of the stomach. IGV includes IGV1, which are those located in the fundus of the stomach and also called fundal varices, and IGV2, which refer to ectopic varices located anywhere in the stomach (Figure 1). This classification, initially described by Sarin et al,[1] has important clinical implications regarding incidence, risk of bleeding, and management. According to Sarin et al, GOV1 represent almost 75%, GOV2 21%, IGV1 less than 2%, and IGV2 4% of all GV. GOV1 are a continuation of esophageal varices and share the same vascular anatomy and response to treatment and thus will not be further discussed. This review will mainly focus on the management of IGV1 and GOV2, the so-called cardiofundal varices. Data regarding prevalence, bleeding risk, and management of IGV2 are scarce, and therefore no specific recommendations are made on this type of GV. However, in our center the management of IGV2 is similar to that of IGV1. Although recent studies specifically detail the different types of GV, most of the available data comes from series of patients with mixed types of GV and portal hypertension etiologies (cirrhotic and noncirrhotic), and the results may not be applicable to all types of GV. As a result, the optimal treatment of gastric fundal varices has not fully been determined.

Figure 1.

Sarin's classification of GV. Modified with permission from the American Gastroenterological Association (AGA) Institute Gastroslides - Cirrhosis and Portal Hypertension.

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