What are the Kiyosue and Sarin classifications of gastric varices?

Kiyosue and Sarin Classifications of Gastric Varices

The Sarin classification is the most widely used clinical classification for gastric varices based on endoscopic appearance, while the Kiyosue classification focuses on angiographic findings and is essential for planning interventional procedures. 1

Sarin Classification (Endoscopic)

This classification is based on the location of gastric varices and their relationship with esophageal varices:

1. Gastroesophageal Varices (GOV): Continuous with esophageal varices

   • GOV1: Extend along the lesser curvature of the stomach (most common, ~74% of cases)
   • GOV2: Extend along the fundus of the stomach

2. Isolated Gastric Varices (IGV): Occur in the absence of esophageal varices

   • IGV1: Located in the fundus
   • IGV2: Located elsewhere in the stomach (body, antrum, pylorus, or duodenum)

Kiyosue Classification (Angiographic)

This classification is based on vascular anatomy and is divided into three components:

1. Inflow Classification: Based on the feeding vessels

   • Type 1: Single inflow from posterior/short gastric vein
   • Type 2: Multiple inflows from posterior/short gastric veins
   • Type 3: Multiple inflows from both posterior/short gastric veins and left gastric vein

2. Outflow Classification: Based on drainage patterns

   • Type A: Single gastrorenal shunt without other collateral veins
   • Type B: Predominant gastrorenal shunt with small collateral veins
   • Type C: Gastrorenal shunt with large collateral veins
   • Type D: Multiple collateral veins without a gastrorenal shunt

3. Variceal Filling Pattern: Based on balloon-occluded retrograde venography

   • Grade 1: Minimal filling of gastric varices
   • Grade 2: Partial filling of gastric varices
   • Grade 3: Complete filling of gastric varices without collaterals
   • Grade 4: Complete filling with opacification of collaterals
   • Grade 5: Complete filling with extensive opacification of collaterals

Clinical Significance and Management Implications

Sarin Classification

• GOV1: Managed similar to esophageal varices (band ligation, beta-blockers) 1
• GOV2/IGV1: Higher bleeding risk; require specialized treatments like cyanoacrylate injection, BRTO, or PARTO 1
• IGV2: Rare; management depends on location and feeding vessels

Kiyosue Classification

• Essential for planning interventional procedures like BRTO (Balloon-occluded Retrograde Transvenous Obliteration) 2, 3
• Helps determine feasibility of procedures based on presence of gastrorenal shunts
• Guides technical approach for obliteration procedures

Vascular Anatomy Considerations

• Gastric varices typically develop through two main portosystemic collateral systems:

  1. Gastrophrenic Venous System: Primary pathway for isolated gastric varices
  2. Gastroesophageal (Azygous) Venous System: Primary pathway for GOV1 2, 4

• Portal pressure in isolated gastric varices is often lower than in esophageal varices (262±44 vs. 358±66 mmH₂O) 4

• Gastric varices with gastrorenal shunts may bleed at lower portal pressures than esophageal varices 1, 2

Important Clinical Considerations

• Cross-sectional imaging (CT or MRI) with portal venous phase is essential after initial endoscopic evaluation to determine vascular anatomy 1, 2

• Risk factors for gastric variceal bleeding include:

  • Location (IGV1>GOV2>GOV1)
  • Large size (>10mm)
  • Presence of red spots
  • Severe liver dysfunction 1, 5

• Treatment decisions should be based on both endoscopic classification and vascular anatomy, ideally through multidisciplinary discussion between gastroenterologists and interventional radiologists 1, 2

Pitfalls to Avoid

• Relying solely on endoscopic classification without cross-sectional imaging may lead to suboptimal treatment decisions 1, 2

• Attempting BRTO in patients with portal vein occlusion without proper angiographic assessment can lead to serious complications 2

• Treating GOV1 with techniques designed for fundal varices may be unnecessary and potentially harmful 1

• Failing to identify the presence of a gastrorenal shunt before planning interventional procedures 2, 3

Understanding both classifications is crucial for comprehensive management of gastric varices, with the Sarin classification guiding initial endoscopic assessment and the Kiyosue classification informing interventional radiological approaches.