What is the recommended primary prophylaxis for gastric variceal bleeding in a patient with a history of liver disease, likely cirrhosis?

Primary Prophylaxis for Gastric Variceal Bleeding

The recommended primary prophylaxis for gastric variceal bleeding depends critically on the anatomic location and size of the varices: for GOV1 (gastroesophageal varices along the lesser curvature), follow esophageal variceal prophylaxis guidelines with non-selective beta-blockers or endoscopic variceal ligation; for GOV2 (fundal gastroesophageal varices) and IGV1 (isolated gastric varices in the fundus) at high risk, endoscopic variceal obturation (EVO), balloon-occluded retrograde transvenous obliteration (BRTO), or vascular plug-assisted retrograde transvenous obliteration (PARTO) are superior to observation and should be considered first-line interventions. 1

Classification and Risk Stratification

Gastric varices require anatomic classification before determining prophylaxis strategy:

• GOV1 varices extend along the lesser curvature from the esophagus and represent approximately 74% of gastric varices 1
• GOV2 varices extend into the gastric fundus 1
• IGV1 varices are isolated fundal varices 1
• IGV2 varices occur in other gastric locations or duodenum 1

Risk factors for bleeding include location (IGV1 > GOV2 > GOV1), variceal size >10mm, presence of red color signs on endoscopy, and severe liver dysfunction (Child-Pugh B/C) 1

Treatment Algorithm by Variceal Type

GOV1 Varices (Lesser Curvature)

For GOV1 varices, follow the same prophylaxis strategy as esophageal varices 1:

• Non-selective beta-blockers (NSBBs) are first-line therapy, with propranolol starting at 40mg twice daily and titrating to 80mg twice daily, targeting a hepatic venous pressure gradient <12 mmHg 1
• Endoscopic variceal ligation (EVL) is the alternative for patients with contraindications or intolerance to NSBBs 1
• In one Korean study, 64.7% of GOV1 varices disappeared when esophageal varices were eliminated by EVL 1

GOV2 and IGV1 Varices (Fundal Varices)

For fundal varices (GOV2 and IGV1), particularly those >10mm or with high-risk features, interventional therapy is superior to medical management:

Evidence-Based Intervention Hierarchy:

BRTO demonstrates the highest efficacy with a 97.3% clinical success rate in preventing gastric variceal bleeding and achieves complete variceal eradication in 75.6% of patients 1, 2

EVO (endoscopic variceal obturation with cyanoacrylate) is highly effective, reducing bleeding risk to 10% compared to 38% with NSBBs and 53% with observation alone, with a 93% survival rate 1, 2

PARTO (vascular plug-assisted retrograde transvenous obliteration) is a safe alternative that effectively prevents gastric variceal bleeding without serious side effects 1

NSBBs remain an option for patients who cannot undergo interventional procedures, though they are less effective than EVO or BRTO for fundal varices 1

Key Clinical Trial Data:

A randomized study of 89 patients with GOV2 or IGV1 >10mm compared three strategies 1:

• EVO: 10% bleeding rate, 93% survival
• NSBB: 38% bleeding rate, 83% survival
• Observation: 53% bleeding rate, 73% survival

A retrospective analysis of 210 patients confirmed that both EVO and BRTO significantly reduce bleeding compared to observation (19.4% EVO, 7.3% BRTO, 35.1% observation; p=0.001), with BRTO achieving superior complete eradication rates 2

Surveillance Strategy

All cirrhotic patients should undergo endoscopy at diagnosis to identify and classify varices 1:

• No varices detected: repeat endoscopy every 3 years 1
• Small varices: repeat endoscopy yearly 1
• Large varices (grade 3) or grade 2 varices with Child B/C disease: initiate primary prophylaxis 1

Common Pitfalls and Caveats

Do not apply esophageal variceal prophylaxis guidelines uniformly to all gastric varices - GOV2 and IGV1 require different management than GOV1 1

Avoid sclerotherapy for primary prophylaxis - it has been shown to increase mortality and should not be used 1

Do not use shunt therapy (TIPS or surgical shunts) for primary prophylaxis - these are reserved for treatment of acute bleeding or secondary prophylaxis failures 1

Consider local expertise and resources when choosing between EVO, BRTO, and PARTO, as these are technically demanding procedures requiring specialized skills 1

Monitor for variceal recurrence after successful obliteration, as gastric varices can recur and require ongoing surveillance 1

Special Considerations for High-Risk Patients

Patients with decompensated cirrhosis (Child-Pugh B/C) and fundal varices with red color signs represent the highest-risk group and should be strongly considered for interventional therapy (BRTO, PARTO, or EVO) rather than medical management alone 1

Complete eradication of gastric varices is the sole independent predictor of preventing future bleeding, making BRTO particularly attractive given its 75.6% complete eradication rate compared to 45.8% with EVO 2