What is the management plan for a patient with fundal varix (Internal Gastric Varix) grade 1?

Management of Fundal Varix IGV1

For patients with fundal varices (IGV1), endoscopic variceal obturation (EVO) with tissue adhesives such as cyanoacrylate should be the first-line treatment, followed by consideration of transjugular intrahepatic portosystemic shunt (TIPS) or retrograde transvenous obliteration (RTO) in high-risk patients. 1

Initial Assessment and Management

Classification and Risk Assessment

• IGV1 (isolated gastric varices type 1) are located in the fundus of the stomach
• Risk factors for bleeding from fundal varices include:
  • Large size (>5 mm)
  • Presence of red spots
  • Child-Pugh B or C liver status 2

Acute Bleeding Management

1. General measures:

   • Hemodynamic stabilization (maintain hemoglobin around 8 g/dL)
   • Prophylactic antibiotics (ceftriaxone 1g/day IV or norfloxacin 400mg BID)
   • Vasoactive drugs (somatostatin, octreotide, or terlipressin) for 3-5 days 1

2. Endoscopic therapy:

   • Endoscopic variceal obturation (EVO) with cyanoacrylate glue is the first-line treatment for fundal varices 1
   • Cyanoacrylate injection has shown better control of initial hemorrhage and lower rebleeding rates compared to band ligation or sclerotherapy 1
   • Conventional sclerotherapy has poor efficacy for IGV1, with only 26% success rate in controlling active bleeding 1

3. If endoscopic therapy fails:

   • Balloon tamponade can be used as a temporary bridging therapy (maximum 24 hours) 1
   • TIPS or retrograde transvenous obliteration (BRTO/PARTO) should be considered as rescue therapy 1

Prevention of Rebleeding

Endoscopic Management

• Repeated EVO sessions to eradicate gastric varices 1
• Unlike esophageal varices, non-selective beta-blockers (NSBBs) have not shown efficacy in preventing rebleeding from fundal varices 1
• A randomized controlled trial showed that eradication of gastric varices with repeated EVO significantly lowered rebleeding rates compared to NSBBs (10% vs. 44%) 1

Radiological Interventions

• For high-risk patients (Child-Pugh B or C):
  • Consider pre-emptive TIPS within 72 hours, which has shown improved rebleeding-free survival compared to endoscopic therapy alone 3
  • Retrograde transvenous obliteration (BRTO or PARTO) can be considered if an accessible gastrorenal shunt is present 1

Primary Prophylaxis

• For patients with large fundal varices who have never bled, cyanoacrylate injection has shown superior efficacy compared to beta-blockers in preventing first gastric variceal bleeding (13% vs. 28% bleeding rate) 4

Follow-up and Monitoring

• Regular endoscopic surveillance after variceal eradication
• Monitor for development of portal hypertensive gastropathy, which occurs in approximately 60% of patients 5
• Be vigilant for shunt dysfunction in patients who received TIPS

Important Considerations

• Unlike esophageal varices, fundal varices can bleed at lower portal pressure gradients due to the high frequency of spontaneous gastrorenal shunts 2
• Endoscopic band ligation should NOT be used for fundal varices unless the varix is small enough to be completely suctioned into the ligation device 1
• The combination of EVO plus NSBBs has not shown additional benefit over EVO alone for fundal varices 1

The management of fundal varices differs significantly from esophageal varices, requiring specialized approaches with tissue adhesives as first-line therapy and early consideration of radiological interventions in high-risk patients.