Does ligation of esophageal varices increase the risk of bleeding from fundal varices in patients with a history of liver disease?

Does Ligation of Esophageal Varices Increase the Risk of Bleeding from Fundal Varices?

Endoscopic variceal ligation (EVL) of esophageal varices does not increase the risk of bleeding from fundal varices; in fact, when GOV1 (gastroesophageal varices type 1) are present, they frequently disappear when esophageal varices are eradicated by EVL. 1

Understanding the Relationship Between Esophageal and Gastric Varices

The key to answering this question lies in understanding the classification and hemodynamic relationships of gastric varices:

GOV1 (Gastroesophageal Varices Type 1)

• GOV1 varices extend along the lesser curvature from the esophagus and represent approximately 74% of gastric varices 1
• In a Korean study of 85 patients with GOV1, these varices disappeared in 64.7% of cases when esophageal varices were eliminated by EVL 1
• Primary prevention of bleeding for GOV1 follows the same recommendations as for esophageal varices, meaning EVL is appropriate and beneficial 1

GOV2 and IGV1 (Fundal Varices)

• GOV2 (extending into the gastric fundus) and IGV1 (isolated fundal varices) have different hemodynamics and do NOT typically resolve with esophageal variceal ligation 1
• These fundal varices require different treatment approaches including endoscopic variceal obturation (EVO), BRTO, or PARTO rather than EVL 1, 2

Clinical Algorithm for Management

When EVL is Performed for Esophageal Varices:

For patients with concurrent GOV1:

• EVL of esophageal varices is the appropriate treatment 1
• Expect GOV1 to regress or disappear in approximately two-thirds of cases 1
• No increased risk of fundal bleeding 1

For patients with concurrent GOV2 or IGV1:

• EVL should focus on esophageal varices only 1
• Band ligation should be avoided for large GOV2/fundal varices as it can create dangerous ulcers over these vessels 2
• Fundal varices require separate treatment with cyanoacrylate injection, BRTO, or PARTO 1, 2

Important Caveats and Pitfalls

Critical Distinction in Variceal Types

• The location and classification of gastric varices determines whether EVL affects them 1
• GOV1 shares hemodynamic connections with esophageal varices, explaining why they respond to esophageal EVL 1
• GOV2 and IGV1 have independent blood flow through short gastric and posterior gastric veins, making them unresponsive to esophageal EVL 1

Post-EVL Monitoring

• Post-EVL ulcer bleeding occurs in 2.7-7.8% of patients, typically 10-14 days after band placement 3
• PPI therapy should be administered immediately after EVL (pantoprazole 40 mg IV, then 40 mg oral daily for 9-14 days) to reduce ulcer complications 3
• This represents bleeding from the ligation site itself, not from fundal varices 3

Treatment Failures

• If EVL fails to control bleeding, TIPS should be considered as rescue therapy rather than attempting EVL on fundal varices 1
• For high-risk patients (Child-Pugh B with active bleeding or Child-Pugh C with MELD <14), early TIPS within 72 hours should be considered 1, 2

Evidence Quality and Strength

The strongest evidence comes from the 2020 KASL Clinical Practice Guidelines, which provide Level B1 recommendations based on prospective studies demonstrating that GOV1 varices resolve with esophageal EVL in the majority of cases 1. This directly refutes the concern that esophageal ligation increases fundal bleeding risk—in fact, it reduces it for GOV1 varices.