From the Guidelines
Management of gastric varices without esophageal varices in compensated cirrhotic patients should begin with cyanoacrylate injection (tissue glue) performed endoscopically for acute bleeding, as it has been shown to control bleeding more effectively than endoscopic variceal ligation 1. For primary prophylaxis, non-selective beta-blockers (NSBBs) such as propranolol or nadolol may be considered, although their effectiveness in preventing bleeding from gastric varices is not as well established as it is for esophageal varices. The following key points should be considered in the management of gastric varices:
- Endoscopic variceal obturation with cyanoacryate injection is the recommended first-line treatment for acute bleeding from gastric varices, due to its higher efficacy in controlling bleeding and reducing rebleeding rates compared to endoscopic variceal ligation 1.
- Balloon-occluded retrograde transvenous obliteration (BRTO) or transjugular intrahepatic portosystemic shunt (TIPS) are effective interventional options for patients who fail endoscopic management or have recurrent bleeding despite medical therapy 1.
- Secondary prophylaxis after a bleeding episode should include scheduled follow-up endoscopies every 3-6 months initially, and consideration of continued NSBBs or alternative therapies such as carvedilol.
- The management approach for gastric varices differs from esophageal varices due to their distinct hemodynamics and frequent involvement of gastro-renal shunts, making them more amenable to interventional radiological approaches than endoscopic techniques alone 1.
From the Research
Management of Gastric Varices
The management of gastric varices without esophageal varices in compensated cirrhotic patients is a complex issue.
- Gastric varices are categorized into four types based on their location within the stomach and relationship with esophageal varices, as described by Sarin's classification 2.
- Treatment options for gastric varices include beta-blockers, endoscopic band ligation, endoscopic cyanoacrylate injection, EUS-guided coil/cyanoacrylate injection, transjugular intrahepatic portosystemic shunts, and balloon-occluded retrograde transvenous obliteration 2, 3.
Treatment Strategies
- The best treatment strategy for gastric varices remains controversial due to the heterogeneity of gastric varices, lack of high-quality data, and suboptimal trial design of available studies 2.
- A multidisciplinary approach involving hepatologists, therapeutic endoscopists, and interventional radiologists is recommended for the management of gastric varices, considering patient characteristics and local expertise 3.
- The addition of non-selective beta-blockers to combined endoscopic treatment may reduce recurrent variceal bleeding in cirrhotic patients with gastric varices, but its effect on overall survival is unclear 4.
Specific Treatment Options
- Balloon-occluded retrograde transvenous obliteration (BRTO) may be an effective treatment for gastric varices without gastro-renal shunt, especially when the drainage vein connects directly to the inferior vena cava 5.
- Endoscopic injection sclerotherapy using alpha-cyanoacrylate glue and percutaneous transhepatic obliteration are also viable options for the treatment of gastric varices, although their efficacy and recurrence rates may vary 5.
- Non-selective beta-blockers may not be effective in preventing the growth of small esophageal varices and may lead to significant adverse effects 6.