What is the initial management for a patient presenting with gastric varices?

Initial Management of Gastric Varices

The initial management for a patient presenting with gastric varices should include prompt hemodynamic stabilization, administration of vasoactive drugs, prophylactic antibiotics, and urgent endoscopy with appropriate endoscopic therapy based on the type of gastric varices. 1

Initial Resuscitation and Medical Management

• Hemodynamic Stabilization:

  • Admit to intensive care unit for close monitoring
  • Assess airway and obtain peripheral venous access
  • Blood volume resuscitation with a target hemoglobin of approximately 8 g/dL (7-9 g/dL)
  • Avoid vigorous saline resuscitation which can precipitate rebleeding 1
  • Consider tracheal intubation for airway protection, especially in patients with hepatic encephalopathy

• Pharmacological Therapy:

  • Start vasoactive drugs (terlipressin, octreotide, or somatostatin) as soon as gastric variceal bleeding is suspected 1, 2
  • Continue vasoactive drugs for up to 5 days after bleeding control 2
  • Temporarily suspend beta-blockers during acute bleeding episodes 1

• Prophylactic Antibiotics:

  • Administer short-course prophylactic antibiotics (e.g., ceftriaxone) to reduce risk of infection, rebleeding, and mortality 1, 2

Diagnostic Evaluation

• Endoscopy:
  • Perform urgent endoscopy within 24 hours of presentation 1
  • Classify gastric varices according to Sarin's classification:
    • GOV1: Esophageal varices extending below cardia into lesser curvature (75% of gastric varices)
    • GOV2: Esophageal varices extending into fundus
    • IGV1: Isolated gastric varices in fundus
    • IGV2: Isolated gastric varices elsewhere in stomach 1

Endoscopic Management Based on Variceal Type

For GOV1 (Gastroesophageal Varices Type 1)

• Manage according to esophageal variceal guidelines 1
• Endoscopic variceal band ligation is the first-choice treatment 1

For GOV2 and IGV1 (Fundal Varices)

• Cyanoacrylate injection is the treatment of choice for acute bleeding 1, 3

  • More effective than band ligation for controlling active bleeding and preventing rebleeding 1
  • Success rate of approximately 90% for initial hemostasis 1
  • Use N-butyl-2-cyanoacrylate or 2-octyl cyanoacrylate 1

• Alternative endoscopic options if cyanoacrylate unavailable:

  • Endoscopic sclerotherapy (less effective, with control rates of 70-80%) 1
  • Thrombin injection 1
  • Avoid band ligation for large fundal varices due to high risk of catastrophic rebleeding 1

Rescue Therapies for Failed Endoscopic Management

• Balloon Tamponade:

  • Use Sengstaken-Blakemore tube with gastric balloon or Linton-Nachlas tube as a temporary bridge to definitive treatment 1
  • Effective for immediate control but rebleeding is almost universal without additional treatment 1

• Transjugular Intrahepatic Portosystemic Shunt (TIPS):

  • Consider for treatment failures or rebleeding after initial endoscopic management 1
  • More effective than endoscopic therapy in preventing rebleeding but associated with higher rates of encephalopathy 1

• Balloon-Occluded Retrograde Transvenous Obliteration (BRTO):

  • Consider for patients with gastric varices with spontaneous gastrorenal shunts 3
  • Particularly useful for patients who may not tolerate TIPS 3

Special Considerations

• Risk factors for gastric variceal bleeding:

  • Large size (>5mm)
  • Presence of red spots
  • Severe liver dysfunction (Child-Pugh C)
  • Location (IGV1 > GOV2 > GOV1) 1, 4

• Pitfalls to avoid:

  • Do not delay administration of vasoactive drugs while waiting for endoscopy
  • Avoid overtransfusion (target Hgb 7-9 g/dL) as it can increase portal pressure and rebleeding risk 1
  • Do not use band ligation for large fundal varices due to risk of catastrophic rebleeding 1
  • Remember that unlike esophageal varices, gastric varices can bleed at portal pressure gradients <12 mmHg 4

Following initial control of bleeding, patients should be evaluated for secondary prophylaxis with repeated cyanoacrylate injections and non-selective beta-blockers to prevent rebleeding 1, 3.