What is the management approach for gastric varices classified as GOV2 (Gastroesophageal Varices type 2) or F2 (Fundal Varices type 2)?

Management of GOV2 and F2 Gastric Varices

For GOV2 (gastroesophageal varices type 2) and fundal varices, endoscopic cyanoacrylate injection is the first-line treatment for acute bleeding, achieving superior hemostasis and lower rebleeding rates compared to band ligation, with TIPS or BRTO reserved for treatment failures or high-risk patients. 1, 2

Primary Prevention (Non-Bleeding GOV2/Fundal Varices)

Risk Stratification

• High-risk features include large size (>10 mm), presence of red spots/color signs, and decompensated cirrhosis 1
• Risk of bleeding is intermediate: IGV1 > GOV2 > GOV1 1

Treatment Options for High-Risk Patients

• Endoscopic variceal obturation (EVO) with cyanoacrylate is superior to non-selective beta-blockers (NSBBs) for primary prevention, with bleeding rates of 10% vs 38% vs 53% (observation) 1
• BRTO or PARTO achieve 97.3% clinical success rates in preventing first bleeding and should be considered for high-risk patients 1
• NSBBs can be used as a non-invasive option, though data are weaker than for esophageal varices 1
• TIPS is NOT recommended for primary prevention in patients who have never bled 1

Acute Bleeding Management

Initial Resuscitation (Before Endoscopy)

• Start vasoactive drugs immediately upon suspicion: octreotide 50 µg IV bolus then 50 µg/hour infusion, or terlipressin 2 mg IV every 4 hours, continuing for 3-5 days 2, 3
• Administer prophylactic antibiotics: ceftriaxone 1 g IV every 24 hours for up to 7 days 2, 3
• Restrictive transfusion strategy targeting hemoglobin 7-9 g/dL to avoid increasing portal pressure 2, 3
• Perform endoscopy within 12 hours once hemodynamically stabilized 1, 2, 3

Endoscopic Treatment

• Cyanoacrylate injection (EVO) is first-line therapy for GOV2 and fundal varices, achieving 94% control of active bleeding vs 80% with band ligation 1, 2
• Cyanoacrylate significantly reduces rebleeding compared to band ligation: 18-26% vs 48-86% for fundal varices 1
• Band ligation should be avoided for GOV2 unless varices are small enough to suction both walls into the ligator; otherwise bands fall off leaving ulcers that cause catastrophic rebleeding 1
• N-butyl-2-cyanoacrylate or 2-octyl cyanoacrylate are both effective options 1

Rescue Therapies for Treatment Failures

TIPS (Transjugular Intrahepatic Portosystemic Shunt)

• TIPS is more effective than cyanoacrylate for preventing rebleeding in GOV2, though with higher encephalopathy rates (15-25%) and no survival difference 1
• Consider early/pre-emptive TIPS within 72 hours for high-risk patients (Child-Pugh B with active bleeding or Child-Pugh C), which achieves 100% rebleeding-free survival vs 28% with standard therapy 2, 4
• Use covered stents as current standard of practice for improved patency 1
• TIPS achieves 90-100% hemostasis in rescue settings 1, 2

BRTO/PARTO (Balloon-Occluded Retrograde Transvenous Obliteration)

• BRTO/PARTO achieve >90% hemostasis rates with lower rebleeding risk than TIPS 2, 5
• Requires patent gastrorenal or gastrocaval shunt for technical feasibility 1
• Obtain contrast-enhanced CT or MRI to identify inflow/outflow vessels and determine BRTO feasibility 1
• Potential benefit of increasing portal hepatic blood flow, making it preferable for patients who may not tolerate TIPS 5
• Caution: BRTO obliterates spontaneous portosystemic shunts, potentially aggravating portal hypertension 5

Balloon Tamponade

• Linton-Nachlas tube serves as temporary bridge therapy for up to 24 hours maximum in massive uncontrolled bleeding 1, 2
• Sengstaken-Blakemore or Minnesota tubes can be used with gastric balloon inflation only, anchored against gastroesophageal junction 1

Secondary Prevention (After Bleeding Episode)

• Repeated cyanoacrylate injection sessions plus NSBBs are recommended as standard secondary prophylaxis 6, 5
• Cyanoacrylate is superior to beta-blockers alone for secondary prevention: 15% vs 55% rebleeding rate and 3% vs 25% mortality 6
• TIPS may be considered for secondary prevention, particularly in Child-Pugh B or C patients, though comparative data with cyanoacrylate are limited 4, 5

Critical Pitfalls to Avoid

• Do NOT use band ligation for large GOV2/fundal varices as bands will fall off, creating dangerous ulcers over vessels 1
• Do NOT use TIPS or BRTO for primary prevention in patients who have never bled 1
• Do NOT withhold beta-blockers during acute bleeding as they decrease blood pressure inappropriately 3
• Ensure adequate training in cyanoacrylate injection technique as complications include embolization; consider EUS-guided coil placement as emerging alternative 1