From the Guidelines
Gastric varices are abnormally enlarged veins in the stomach that develop due to increased pressure in the portal venous system, a condition called portal hypertension, and they pose a significant risk of severe, potentially life-threatening bleeding. These dilated blood vessels form when blood flow through the liver is obstructed, commonly due to liver cirrhosis, causing blood to seek alternate pathways through smaller vessels in the stomach 1. Gastric varices are classified based on their location, with those near the esophagus (gastroesophageal varices) and those in isolated areas of the stomach (isolated gastric varices) being the main types.
Classification and Risk
The classification of gastric varices is crucial for determining the best course of treatment. According to the guidelines, gastric varices extending from esophageal varices along the lesser curvature (GOV1s) can be treated with either endoscopic variceal obturation (EVO) or endoscopic variceal ligation (EVL), depending on the size and location of the bleeding varix 1.
Treatment Options
Treatment options for gastric varices include:
- Endoscopic procedures such as injection of tissue adhesives or banding
- Transjugular intrahepatic portosystemic shunt (TIPS) to redirect blood flow
- Balloon-occluded retrograde transvenous obliteration (BRTO)
- Medications like beta-blockers to reduce portal pressure In patients with bleeding from fundic varices (GOV2s, IGV1s), EVO should be considered first 1. Retrograde transvenous obliteration (BRTO or PARTO) or TIPS can be used depending on the bleeding status and the presence of an accessible shunt 1.
Management of Acute Hemorrhage
The initial treatment of gastric variceal hemorrhage is similar to that of esophageal variceal hemorrhage, including volume resuscitation, vasoactive drugs, and antibiotics before diagnostic endoscopy 1. In case of massive bleeding, balloon tamponade with the Linton-Nachlas tube may serve as a bridge to other treatments 1.
Prevention of Bleeding Complications
Patients with gastric varices require regular monitoring through endoscopy and management of the underlying liver disease to prevent bleeding complications 1. A proton pump inhibitor (PPI) can be used following endoscopic treatments to prevent post-procedure ulcer bleeding 1. Unlike esophageal varices, gastric varices often bleed more severely and can be more challenging to treat effectively 1.
From the Research
Definition of Gastric Varix
- A gastric varix is a dilated submucosal vein in the stomach, often associated with portal hypertension and cirrhosis 2.
- Gastric varices are a type of gastrointestinal variceal hemorrhage, which can be a substantial cause of morbidity and mortality 2.
Characteristics of Gastric Varix
- Gastric varices are less common than esophageal varices but can still cause severe gastrointestinal bleeding 2.
- The goals of managing variceal hemorrhage, including gastric varices, are control of active bleeding and prevention of rebleeding 2.
Treatment of Gastric Varix
- The treatment of gastric varices often involves endoscopic variceal ligation (EVL) or obliteration using cyanoacrylate 3.
- Pharmacologic therapy, such as beta-blockers, may also be used to reduce the risk of variceal bleeding, although its effectiveness in gastric varices is not as well established as in esophageal varices 4, 5, 6.