What is a junctional varix?

Junctional Varix Definition

A junctional varix is a dilated vein located at the gastroesophageal junction, specifically classified as gastroesophageal varices type 1 (GOV1), which extends from the esophagus along the lesser curvature of the stomach.

Anatomical Classification and Characteristics

Junctional varices are a specific type of gastroesophageal varices that form at the junction between the esophagus and stomach. They are classified within the established gastric varix classification system:

• GOV1 (Gastroesophageal Varices Type 1): These are junctional varices that extend from the esophagus along the lesser curvature of the stomach 1
• GOV2 (Gastroesophageal Varices Type 2): These extend from the esophagus into the gastric fundus
• IGV1 (Isolated Gastric Varices Type 1): Located in the fundus without esophageal varices
• IGV2 (Isolated Gastric Varices Type 2): Located in other regions of the stomach or duodenum

Pathophysiology

Junctional varices develop as a result of portal hypertension, most commonly due to cirrhosis. The increased pressure in the portal venous system leads to the formation of collateral vessels, including those at the gastroesophageal junction 1. These varices form when:

• Portal blood flow is diverted through collateral vessels due to increased resistance in the liver
• Blood flow becomes hepatofugal (away from the liver) through these varices toward systemic circulation 2
• The left gastric vein (coronary vein) is typically the primary vessel involved in these shunts 2

Clinical Significance

Junctional varices (GOV1) are the most common type of gastric varices, accounting for approximately 74% of all gastric varices 1. Their clinical importance stems from:

1. Bleeding Risk: While they bleed less frequently than esophageal varices, when they do bleed, the risk of rebleeding and mortality is higher 1

2. Management Approach: GOV1 varices are managed similarly to esophageal varices, unlike other types of gastric varices that require different treatment approaches 1

3. Treatment Options: For bleeding junctional varices, endoscopic variceal ligation (EVL) or cyanoacrylate injection are the primary treatment options 3

Diagnostic Evaluation

Diagnosis of junctional varices is primarily made through:

• Esophagogastroduodenoscopy (EGD): The gold standard for diagnosis 1
• Cross-sectional imaging: Contrast-enhanced CT or MRI can help identify the inflow and outflow vessels and determine the feasibility of interventional procedures 2
• Endoscopic Ultrasound (EUS): Can provide real-time Doppler interrogation of the varices and their feeding vessels 2

Management Considerations

For junctional varices (GOV1):

• Primary prevention: Follow the same guidelines as for esophageal varices, including non-selective beta-blockers (NSBBs) for medium/large varices 1
• Acute bleeding: Endoscopic therapy with either EVL or cyanoacrylate injection is effective 3
• Secondary prevention: Combination of EVL plus NSBBs is recommended 1

Important Clinical Distinctions

It's crucial to distinguish junctional varices (GOV1) from other types of gastric varices because:

1. They respond differently to treatment modalities
2. They have different bleeding risks and patterns
3. They require specific management approaches based on their anatomical location

Understanding the specific classification of junctional varices as GOV1 helps guide appropriate management decisions and improves patient outcomes.