Gastric Varices Classification According to the Sarin System
The Sarin classification divides gastric varices into four types based on their anatomical location and relationship to esophageal varices: GOV1 (gastroesophageal varices extending along the lesser curve), GOV2 (gastroesophageal varices extending into the fundus), IGV1 (isolated fundal varices), and IGV2 (isolated varices elsewhere in the stomach). 1
The Four Types of Gastric Varices
Gastroesophageal Varices (GOV)
These varices are continuous with esophageal varices:
GOV Type 1 (GOV1): Esophageal varices that extend below the gastroesophageal junction along the lesser curvature of the stomach. This is the most common type, accounting for approximately 75% of all gastric varices 1, 2. These varices share similar vascular supply with esophageal varices and are often referred to as "lesser curve varices" 3.
GOV Type 2 (GOV2): Esophageal varices that extend into the gastric fundus along the greater curvature 1. These are grouped with IGV1 as "cardiofundal varices" because they have distinct vascular supply from esophageal varices 3, 1.
Isolated Gastric Varices (IGV)
These varices occur without associated esophageal varices:
IGV Type 1 (IGV1): Varices located in the gastric fundus without connection to esophageal varices 1, 2. Along with GOV2, these are classified as cardiofundal varices 3, 1.
IGV Type 2 (IGV2): Isolated varices located anywhere else in the stomach (gastric body, antrum, or pylorus) 1. This type is extremely rare in clinical practice 1, 4.
Clinical Significance of Classification
The Sarin classification is critical because different types have distinct bleeding risks and require different management approaches 1:
Bleeding Risk Hierarchy
- IGV1 has the highest bleeding risk (78% bleeding rate), followed by GOV2 (55%), then GOV1 (lowest risk) 2, 5
- Gastric varices bleed at lower portosystemic pressure gradients than esophageal varices (mean 19 mm Hg vs 23 mm Hg), with IGV1 bleeding at the lowest pressures (16 mm Hg) 5
- When gastric varices do bleed, they cause more severe hemorrhage requiring more transfusions (4.8 vs 2.9 units) and have higher mortality (45%) compared to esophageal varices 2
Management Implications
- GOV1 behaves similarly to esophageal varices and can be managed with band ligation, though 59% disappear after esophageal variceal obliteration 3, 2
- GOV2 and IGV1 (cardiofundal varices) require different treatment—cyanoacrylate injection is superior to band ligation for these types, with significantly lower rebleeding rates 1
- IGV2 is often associated with splenic vein thrombosis and may require splenectomy rather than endoscopic therapy 3
Simplified Alternative Classification
The 2021 AGA guideline proposes a more intuitive classification system that may be easier to apply clinically 3:
- Cardiofundal GV (encompasses GOV2 and IGV1)
- Lesser curve GV (corresponds to GOV1)
- Distal GV (corresponds to IGV2)
This simplified approach recognizes that cardiofundal varices have distinct vascular supply and require different management than lesser curve varices, making treatment decisions more straightforward 3.
Key Clinical Pitfall
Always obtain cross-sectional imaging (CT or MRI with portal venous phase) before definitive treatment to identify splenic vein thrombosis, portosystemic shunts, or other anatomical variations that fundamentally alter management 3. For example, IGV2 associated with splenic vein thrombosis is best treated with splenectomy rather than endoscopic therapy—a critical distinction that endoscopy alone cannot reveal.