What is the indication for primary prophylaxis in a patient with cirrhosis and medium to large-sized gastric varices who is at high risk of bleeding?

Primary Prophylaxis for Gastric Varices

For patients with cirrhosis and medium to large-sized gastric varices at high risk of bleeding, the indication and treatment strategy depends on variceal location: GOV1 varices should be treated like esophageal varices with non-selective beta-blockers as first-line therapy, while fundal varices (GOV2 and IGV1) larger than 10mm or with high-risk features should receive interventional therapy with BRTO, PARTO, or endoscopic variceal obturation (EVO) rather than medical management alone. 1

Classification and Risk Stratification

Before determining prophylaxis strategy, gastric varices must be anatomically classified 1:

• GOV1 varices extend along the lesser curvature from the esophagus and represent approximately 74% of gastric varices 2, 1
• GOV2 varices extend into the gastric fundus 2
• IGV1 varices are isolated fundal varices 2
• IGV2 varices occur in other gastric locations or duodenum 2

High-risk features for bleeding include 2, 1:

• Location (bleeding risk: IGV1 > GOV2 > GOV1) 2, 1
• Variceal size >10mm 2, 1, 3
• Presence of red color signs on endoscopy 2, 1
• Severe liver dysfunction (Child-Pugh B/C) 2, 1
• MELD score ≥17 3
• Presence of portal hypertensive gastropathy 3

Treatment Algorithm by Variceal Type

GOV1 Varices

Follow the same prophylaxis strategy as esophageal varices 2, 1:

• First-line therapy: Non-selective beta-blockers (propranolol starting at 40mg twice daily, titrating to 80mg twice daily or long-acting formulations at 80-160mg daily) 2, 1, 4
• Target: Reduction in hepatic venous pressure gradient to <12 mmHg 2
• Alternative therapy: Endoscopic variceal ligation for patients with contraindications or intolerance to beta-blockers 2, 1
• Rationale: In one Korean study of 85 patients with GOV1, these varices disappeared in 64.7% of cases when esophageal varices were eliminated by EVL 2

Fundal Varices (GOV2 and IGV1)

For high-risk fundal varices (>10mm or with red color signs, decompensated cirrhosis), interventional therapy is superior to medical management 2, 1:

Primary treatment options 2, 1:

• BRTO (Balloon-occluded retrograde transvenous obliteration): Achieves 97.3% clinical success rate in preventing bleeding and 75.6% complete variceal eradication 1, 5
• PARTO (Vascular plug-assisted retrograde transvenous obliteration): Safe procedure with effective bleeding prevention 2
• EVO (Endoscopic variceal obturation with cyanoacrylate): Reduces bleeding risk to 10% compared to 38% with beta-blockers and 53% with observation, with 93% survival rate 2, 1, 3

Comparative efficacy data 3, 5:

• In a randomized controlled trial of 89 patients with GOV2 or IGV1 >10mm, EVO was superior to beta-blockers and observation for preventing first gastric variceal bleeding 3
• BRTO demonstrates superior complete eradication rates compared to EVO (75.6% vs 45.8%, p=0.003), and complete eradication is the sole determinant for predicting future bleeding 5
• Both EVO and BRTO significantly reduce bleeding compared to observation alone (EVO vs observation p=0.038; BRTO vs observation p=0.001) 5

Beta-blockers as alternative: Non-selective beta-blockers can be used for patients who cannot undergo interventional procedures, though they are less effective than EVO or BRTO for fundal varices 2, 3

Surveillance Strategy

All cirrhotic patients require endoscopy at diagnosis to identify and classify varices 2, 1:

• No varices detected: Repeat endoscopy every 3 years 2, 1
• Small varices: Repeat endoscopy yearly 2
• Grade 2 varices with Child B/C disease: Initiate primary prophylaxis 2
• Grade 3 (large) varices: Initiate primary prophylaxis regardless of liver disease severity 2

Critical Clinical Considerations

Contraindications to beta-blockers 4, 6:

• Hypotension or severe bradycardia
• Heart block
• Asthma or severe COPD
• Decompensated heart failure
• Active variceal bleeding

Common pitfall: Do not treat all gastric varices the same way. GOV1 varices respond well to beta-blockers following esophageal variceal protocols, but fundal varices (GOV2/IGV1) require interventional therapy for optimal outcomes 2, 1, 3.

Important caveat: While beta-blockers decrease hepatic venous pressure gradient (from 14 to 12 mmHg), cyanoacrylate injection paradoxically increases HVPG (from 14 to 15 mmHg), yet still provides superior bleeding prevention for fundal varices 3. This highlights that the mechanism of protection differs between medical and interventional approaches.

For decompensated cirrhosis patients (Child-Pugh B/C) with fundal varices and red color signs, strongly consider interventional therapy (BRTO, PARTO, or EVO) as first-line rather than beta-blockers alone 1.