What is the management approach for gastric varices?

Management of Gastric Varices

For gastric variceal bleeding, endoscopic cyanoacrylate injection is the preferred definitive therapy for cardiofundal varices, while band ligation is appropriate for lesser curve varices, with interventional radiological approaches like BRTO or TIPS reserved for refractory cases based on vascular anatomy. 1

Classification and Initial Assessment

Gastric varices (GV) are classified based on location:

• Lesser curve varices (similar to GOV1): Extend from esophageal varices along lesser curvature
• Cardiofundal varices (similar to GOV2/IGV1): Located on posterior/greater curvature side of cardia
• Distal gastric varices (similar to IGV2): Located in gastric body or antrum 1

Acute Management of Bleeding Gastric Varices

Initial Resuscitation

• Secure adequate vascular access
• Transfuse blood products to maintain hemoglobin 7-9 g/dL
• Start octreotide (50 μg IV bolus followed by 50 μg/hour infusion for 2-5 days)
• Administer prophylactic antibiotics (ceftriaxone 1g IV daily for up to 7 days) 1, 2

Endoscopic Evaluation and Temporizing Measures

• Perform urgent endoscopy within 12 hours of presentation
• For active bleeding requiring temporizing measures:
  • Band ligation for lesser curve varices
  • Gastric compression balloons (Sengstaken-Blakemore or Linton-Nachlas tube) for cardiofundal varices if expertise available 1

Definitive Management Based on Variceal Type

1. Lesser Curve Varices

• First-line: Endoscopic band ligation (similar to esophageal varices)
• Refractory cases: TIPS placement 1, 2

2. Cardiofundal Varices

• First-line: Endoscopic cyanoacrylate injection (ECI)
  • Use 4-carbon (butyl) cyanoacrylate preparations (faster polymerization)
  • Avoid mixing with lipiodol or other oils (increases embolization risk)
  • Follow detailed injection protocol (see below)
• Alternative/Refractory cases: Based on vascular anatomy determined by CT/MRI:
  • If gastrorenal shunt present: BRTO (lower encephalopathy risk than TIPS)
  • If no gastrorenal shunt or severe portal hypertension complications: TIPS with direct embolization 1, 2

3. Distal Gastric Varices

• Evaluate for splenic vein thrombosis (common cause)
• Consider splenectomy for isolated splenic vein thrombosis
• Otherwise, manage similarly to cardiofundal varices 1

Cyanoacrylate Injection Technique for Cardiofundal Varices

Preparation

1. Draw 15-20cc neutral oil in 60cc syringe
2. Connect endoscopic injector needle (19-23g) to 3-way stopcock
3. Draw 5cc sterile water into 5-10cc syringe
4. Connect sterile water to side port of stopcock
5. Draw 2mL cyanoacrylate into 5-10cc syringe (prepare 2-4 syringes)
6. Cap syringes and place on ice to prevent polymerization 1

Injection Procedure

1. Connect cyanoacrylate syringe to end of 3-way stopcock
2. Test needle patency with 1.5cc sterile water
3. Inject 5cc oil into working channel of endoscope
4. Insert injector needle through working channel
5. Prime injector needle with 1.5mL cyanoacrylate in gastric body
6. Position at varix site (away from active bleeding)
7. Insert needle into varix and inject cyanoacrylate rapidly (4-5 seconds)
8. Switch stopcock to water and flush contents
9. Remove needle while still injecting final amounts of water
10. Monitor injection site for 5-10 seconds 1

Follow-up and Surveillance

• After endoscopic treatment:

  • Repeat endoscopy every 2-4 weeks until complete obliteration
  • For cyanoacrylate-treated varices: palpate with blunt instrument or Doppler probe to check for residual flow
  • After confirmed eradication: endoscopy at 3-6 months, then yearly 1, 2

• After BRTO:

  • Endoscopic assessment within 48 hours to confirm variceal obliteration
  • Cross-sectional imaging within 4-6 weeks
  • Monitor for development/worsening of esophageal varices (common after BRTO) 1

• After TIPS:

  • Endoscopic examination 1 month after procedure
  • Monitor for hepatic encephalopathy (higher risk with TIPS than BRTO) 1

Common Pitfalls and Complications

Cyanoacrylate Injection Complications

• Embolization (pulmonary or systemic)
• Needle impaction in varix
• Exacerbation of bleeding
• Portal vein thrombosis
• Infection 1

Post-BRTO Complications

• Worsening of esophageal varices (30-35% progress in size)
• Development/worsening of ascites or hydrothorax (15% clinically significant) 1

Post-TIPS Complications

• Hepatic encephalopathy (higher risk than with BRTO)
• Hepatic ischemia (especially with gastrorenal shunt) 1

Multidisciplinary Approach

Management of bleeding gastric varices requires collaboration between hepatologists, interventional radiologists, and interventional endoscopists. Cross-sectional imaging with CT or MRI using portal venous phase contrast is essential for planning definitive therapy and should be obtained before any definitive intervention when possible 1, 2.