What is the treatment for gastric varices?

Treatment of Gastric Varices

For bleeding gastric varices, treatment selection depends critically on varix location and underlying etiology: endoscopic cyanoacrylate injection is first-line for cardiofundal varices in cirrhotic portal hypertension, while splenectomy is definitive for varices due to splenic vein thrombosis from chronic pancreatitis. 1, 2

Initial Management and Diagnostic Evaluation

All patients with suspected gastric variceal bleeding require immediate resuscitation with vasoactive drugs (terlipressin), antibiotics, and correction of coagulopathy, followed by urgent endoscopy for diagnosis and potential treatment. 1, 3

• Obtain contrast-enhanced CT or MRI before definitive therapy to identify varix inflow/outflow patterns, presence of gastrorenal shunt, and detect portal/splenic vein occlusion—this imaging is crucial for determining treatment feasibility and optimal approach. 1, 2
• Endoscopy provides accurate diagnosis but cross-sectional imaging reveals the underlying vascular anatomy that dictates which interventions will succeed 1

Treatment Algorithm Based on Varix Type and Etiology

Cardiofundal Gastric Varices (GOV2/IGV1) with Cirrhotic Portal Hypertension

Endoscopic cyanoacrylate injection (endoscopic variceal obturation) achieves hemostasis in >90% of actively bleeding cardiofundal varices and has significantly lower rebleeding rates than band ligation (18% vs 86% for IGV1). 1, 4

• Cyanoacrylate injection controls active bleeding more effectively than band ligation (94% vs 80%, P=0.03) and should be performed only by trained endoscopists 1
• EUS-guided coil placement with cyanoacrylate improves precision and reduces embolization risk, though not yet recommended for routine use pending comparative data 1
• Repeat endoscopy every 2-4 weeks until complete obliteration is confirmed, then reassess at 3-6 months and yearly thereafter 1

For refractory bleeding or rebleeding after endoscopic therapy, balloon-occluded retrograde transvenous obliteration (BRTO) is superior to TIPS for cardiofundal varices, with lower rebleeding rates and less hepatic encephalopathy. 1, 5

• BRTO requires presence of a gastrorenal shunt for technical feasibility—this is why preprocedural imaging is mandatory 1
• Meta-analysis shows BRTO has similar initial hemostasis to TIPS but significantly less rebleeding and encephalopathy 1
• TIPS combined with direct variceal embolization can be used when BRTO is not feasible due to absent gastrorenal shunt or when severe ascites/esophageal varices require portal decompression 1

Lesser Curve Gastric Varices (GOV1)

Treat GOV1 identically to esophageal varices with endoscopic band ligation as first-line therapy. 1, 6

• GOV1 have much lower bleeding risk than fundal varices and respond well to band ligation 6
• For refractory or recurrent bleeding despite band ligation, TIPS is preferred over BRTO, similar to esophageal varix management 1

Gastric Varices Secondary to Splenic Vein Thrombosis (Sinistral Portal Hypertension)

Splenectomy is the definitive treatment for gastric varices caused by splenic vein occlusion from chronic pancreatitis, with 100% success in controlling bleeding and no recurrence at long-term follow-up. 1, 2

• Splenic vein thrombosis causes isolated left-sided (sinistral) portal hypertension where the entire splenic venous outflow drains through gastric varices 1, 2
• Endoscopic therapy has only 40% success rate versus 100% for splenectomy in this setting 1, 2
• Alternative options when surgery is contraindicated: splenic vein recanalization (if technically feasible) or partial splenic embolization (100% success in diminishing/resolving varices) 1, 7
• TIPS is less effective for sinistral portal hypertension because it doesn't address the isolated splenic venous outflow problem 2

Follow-Up Protocol After Successful Treatment

• Palpate treated cardiofundal varices with blunt instrument or Doppler probe at follow-up endoscopy—areas that dimple or invert require repeat cyanoacrylate injection 1
• After confirmed eradication, perform endoscopy at 3-6 months, then yearly 1
• For de novo or recurrent varices after >12 months, repeat cross-sectional imaging and multidisciplinary discussion to explore alternative mechanisms and consider endovascular approaches 1

Critical Pitfalls to Avoid

• Failure to obtain cross-sectional imaging before definitive treatment leads to misdiagnosis of underlying etiology and selection of inappropriate therapy 2, 7
• Attempting endoscopic therapy alone for splenic vein occlusion results in high failure rates because the underlying hemodynamic problem persists 1, 2
• TIPS placement for cardiofundal varices without direct variceal obliteration allows up to 50% rebleeding rate due to persistent flow through varices at lower portal pressures 1
• Cardiofundal varices bleed at lower portal pressure gradients (<12 mmHg) than esophageal varices, so standard portal pressure reduction may be insufficient 1, 6
• TIPS carries 15-25% risk of hepatic encephalopathy and increases with higher MELD scores—this risk is amplified when gastrorenal shunt is present with cardiofundal varices 1