Management of Non-Bleeding Gastric Varices
For non-bleeding gastric varices, the recommended first-line management approach is nonselective beta-blockers (propranolol or nadolol) titrated to the maximal tolerated dose, with endoscopic variceal ligation (EVL) considered for patients with contraindications or intolerance to beta-blockers. 1
Classification and Risk Assessment
- Gastric varices (GV) are classified based on location as gastroesophageal varices (GOV) or isolated gastric varices (IGV), with fundal varices (GOV2 and IGV1) carrying higher bleeding risk 2, 3
- Risk factors for bleeding include large size (>5 mm), presence of red spots, and Child B/C liver status 2, 3
- The 1-year risk of gastric variceal bleeding is approximately 10-16%, lower than esophageal varices but typically more severe when it occurs 2
Primary Prophylaxis for Non-Bleeding Gastric Varices
Pharmacological Management
- Nonselective beta-blockers (propranolol or nadolol) are the preferred first-line therapy for prevention of first variceal hemorrhage 1, 4
- Beta-blockers reduce portal pressure by decreasing cardiac output and producing splanchnic vasoconstriction 4
- Propranolol should be started at 40 mg daily and titrated to the maximal tolerated dose rather than targeting a specific heart rate reduction 4, 5
- Long-acting propranolol can be used at 80-160 mg daily to improve compliance, with dose reduction to 160 mg maximum in patients with ascites 4
- Carvedilol may provide greater reduction in hepatic venous pressure gradient compared to traditional beta-blockers, though clinical outcome benefits remain uncertain 6
Endoscopic Management
- For gastroesophageal varices type 1 (GOV1), which extend along the lesser curve, endoscopic variceal ligation (EVL) should be considered in patients with contraindications or intolerance to beta-blockers 1
- For fundal varices (GOV2 and IGV1), endoscopic cyanoacrylate injection (ECI) may be more effective than EVL, though data specifically for primary prophylaxis is limited 1, 2
- After EVL, repeat endoscopic evaluation should be performed every 1-3 months until obliteration, then every 6-12 months to check for recurrence 1
Interventions to Avoid
- Nitrates alone should not be used for primary prophylaxis of variceal hemorrhage due to potential increased mortality, especially in patients older than 50 years 1
- Shunt therapy (TIPS or surgical shunts) should not be used for primary prophylaxis due to increased risk of encephalopathy and mortality 1
- Endoscopic sclerotherapy should not be used for primary prophylaxis due to higher mortality compared to sham therapy in randomized trials 1
Monitoring and Follow-up
- For patients on beta-blockers, regular monitoring of heart rate, blood pressure, and renal function is essential 4
- For gastric varices treated endoscopically, repeat endoscopy is recommended every 2-4 weeks until obliteration is complete 1
- After endoscopic eradication, follow-up endoscopy should be performed within 3-6 months and then yearly thereafter 1
- For patients with small varices not receiving beta-blockers, endoscopy should be repeated every 2 years, or annually with hepatic decompensation 4
Special Considerations for Different Types of Gastric Varices
- GOV1 (extending from esophagus along lesser curve) should be managed similarly to esophageal varices 1, 3
- Fundal varices (GOV2 and IGV1) may bleed at lower portal pressures due to frequent gastrorenal shunts 3
- For fundal varices, endoscopic cyanoacrylate injection may be more effective than EVL or beta-blockers alone, though evidence for primary prophylaxis is limited 1, 2
Pitfalls to Avoid
- Contraindications to beta-blockers must be recognized, including asthma, severe COPD, heart block, significant bradycardia, hypotension, and decompensated heart failure 4, 5
- Vigorous fluid resuscitation should be avoided in patients with cirrhosis as it may increase portal pressure and precipitate bleeding 1
- Nitrates should not be combined with beta-blockers for primary prophylaxis due to potential for increased mortality 1