From the Guidelines
The treatment of bleeding gastric varices due to splenic vein thrombosis primarily involves splenectomy as the definitive management, as it addresses the underlying cause by eliminating the left-sided portal hypertension. Initial stabilization includes blood product resuscitation, vasoactive medications like octreotide (50-100 mcg IV bolus followed by 25-50 mcg/hour infusion), and endoscopic therapy 1. For acute bleeding control, endoscopic options include cyanoacrylate glue injection or endoscopic variceal band ligation, though glue is preferred for gastric varices. According to the AGA clinical practice update on management of bleeding gastric varices, initial medical management of bleeding GV should be performed according to current practice guidelines for portal hypertensive bleeding, and goals of initial endoscopic evaluation include identification of the bleeding source and classification of the variceal bleeding site 1.
Some key points to consider in the management of bleeding gastric varices include:
- Determination of definitive therapy for bleeding GV should be made based upon endoscopic appearance of the gastric varix, the underlying vascular anatomy, presence of comorbid portal hypertensive complications, and available local resources 1
- Cross-sectional imaging with portal venous contrast phase should be obtained to determine vascular anatomy, including the presence or absence of portosystemic shunts and gastrorenal shunts 1
- In cases where surgery is contraindicated, transjugular intrahepatic portosystemic shunt (TIPS) or splenic artery embolization may be considered as alternative interventions 1. Once the patient is stabilized, splenectomy addresses the underlying cause by eliminating the left-sided portal hypertension that develops when blood from the spleen is forced to find collateral drainage through short gastric vessels, creating varices. Unlike esophageal varices from cirrhosis, these "left-sided" or "sinistral" portal hypertension varices result from isolated splenic vein obstruction, making splenectomy curative by eliminating the source of abnormal blood flow. Historically, splenectomy has been performed as a standard treatment for gastric variceal bleeding with sinistral portal hypertension, and removal of the spleen should remove the impetus for varix development and pressurization 1.
From the Research
Treatment Options for Bleeding Gastric Varices from Thrombosed Splenic Vein
- Splenectomy is a treatment option for gastric varices that arise from splenic vein thrombosis, as it can help resolve the varices and prevent further bleeding 2, 3
- Splenic artery embolization is another treatment option for bleeding gastric varices secondary to splenic vein thrombosis, which can help reduce blood flow through the spleen and stop variceal bleeding 4, 5
- Endoscopy and endoscopic ultrasound can also play a role in the management of gastric variceal bleeding, including diagnosis, classification, and treatment 6
Considerations for Treatment
- The choice of treatment depends on the individual patient's condition and the underlying cause of the gastric varices
- Splenectomy may be considered for patients with splenic vein thrombosis and gastric varices, especially if other treatment options are not effective or feasible 2, 3
- Splenic artery embolization may be considered for patients who are at high risk for surgery or have failed other treatment options 4, 5