How are fundic varices classified according to the Sarin system, including size grading?

Fundic Varices Classification According to the Sarin System

The Sarin classification divides gastric varices into four types based on their anatomic location and relationship to esophageal varices: GOV1 (gastroesophageal varices extending along the lesser curvature), GOV2 (gastroesophageal varices extending into the fundus), IGV1 (isolated fundic varices), and IGV2 (isolated varices elsewhere in the stomach). 1

The Four Types of Gastric Varices

Gastroesophageal Varices (GOV)

• GOV Type 1 (GOV1): Esophageal varices that extend below the gastroesophageal junction along the lesser curvature of the stomach

  • Most common type, representing approximately 75% of all gastric varices 1
  • Share similar vascular supply with esophageal varices 2
  • Managed following guidelines for esophageal varices 1

• GOV Type 2 (GOV2): Esophageal varices that extend into the gastric fundus

  • Classified as "cardiofundal varices" along with IGV1 1
  • Have distinct vascular supply from esophageal varices 2
  • Higher bleeding risk than GOV1 1

Isolated Gastric Varices (IGV)

• IGV Type 1 (IGV1): Varices located in the gastric fundus without associated esophageal varices

  • Also classified as "cardiofundal varices" 1
  • Highest bleeding risk among all gastric varix types (IGV1 > GOV2 > GOV1) 1
  • Distinct hemodynamic pathways with afferent flow via left gastric vein (75.61%), short gastric vein (63.41%), and posterior gastric vein (43.90%) 3

• IGV Type 2 (IGV2): Varices located elsewhere in the stomach (body, antrum, pylorus)

  • Extremely infrequent 1
  • Often associated with splenic vein thrombosis 2

Simplified Alternative Classification

The 2021 AGA guidelines propose a more intuitive classification system that moves beyond the traditional Sarin approach 2:

• Cardiofundal gastric varices (encompasses GOV2 and IGV1)
• Lesser curve gastric varices (encompasses GOV1)
• Distal gastric varices (rare, often associated with splenic vein thrombosis)

This simplified system better reflects the distinct vascular anatomy and clinical management approaches for different varix locations 2.

Risk Factors for Bleeding

Beyond anatomic classification, key predictors of bleeding risk include 1:

• Location: IGV1 carries highest risk, followed by GOV2, then GOV1
• Size: Larger varices bleed more frequently
• Red color signs: Presence of red spots or wales
• Liver dysfunction severity: Child-Pugh class and MELD score

Clinical Significance

Understanding this classification is critical because bleeding from gastric varices is more severe than esophageal variceal bleeding, with greater transfusion requirements and higher mortality 2. The anatomic classification directly guides therapeutic decisions, as cardiofundal varices (GOV2/IGV1) require different management approaches—typically cyanoacrylate injection or TIPS—compared to lesser curve varices (GOV1), which can be managed similarly to esophageal varices with band ligation 2, 1.