Does EVL Increase the Risk of Bleeding in Fundal Varices?
Yes, EVL significantly increases the risk of catastrophic bleeding in fundal varices (GOV2 and IGV1) and should be avoided in these patients. 1
Why EVL is Dangerous for Fundal Varices
The fundamental problem is anatomical and technical:
EVL should only be performed on small gastric varices where both the mucosal and contralateral wall can be adequately suctioned into the ligator. 1 Fundal varices are typically too large and deep for this to occur safely.
When bands are placed on fundal varices that cannot be properly ligated, the bands fall off within several days, leaving an ulcer directly overlying the vessel. 1 This exposed submucosal varix is then vulnerable to gastric acid and food materials, creating a setup for catastrophic rebleeding.
The gastric mucosa is significantly thicker than esophageal mucosa, making adequate ligation technically difficult or impossible. 1 This anatomical difference means the same technique that works well for esophageal varices fails in the gastric fundus.
Evidence of Poor Outcomes
The clinical data strongly support avoiding EVL in fundal varices:
In a randomized trial of IGV1 bleeding, EVL showed a significantly higher rebleeding rate of 83.3% compared to only 7.7% with endoscopic variceal obturation (EVO). 1 This nearly 11-fold increase in rebleeding demonstrates the danger of using EVL in this setting.
Meta-analysis shows that while EVL and cyanoacrylate injection are equally effective for initial hemostasis in gastric varices, cyanoacrylate is associated with significantly lower rebleeding rates. 1 However, this meta-analysis was dominated by GOV1 varices, not fundal varices.
Appropriate Management of Fundal Varices
For GOV2 and IGV1 (cardiofundal varices), the recommended treatments are: 1
Acute Bleeding
- TIPS is the treatment of choice for controlling acute bleeding from cardiofundal varices. 1
- Cyanoacrylate glue injection is an alternative when TIPS is not technically feasible, though it is not FDA-approved in the United States and should only be performed in centers with expertise. 1
- Initial hemostasis rate with EVO is 91-97%, with rebleeding rates of 17-49%. 1
Prevention of Rebleeding
- TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) are first-line treatments for preventing rebleeding from GOV2 or IGV1. 1
- Cyanoacrylate injection is an option when TIPS or BRTO are not feasible. 1
- In a randomized study, repeated cyanoacrylate injection was superior to non-selective beta-blockers in preventing rebleeding and reducing mortality in patients with cardiofundal varices. 1
When EVL May Be Considered
EVL can be used for GOV1 varices (those extending along the lesser curvature), as these behave more like esophageal varices. 1 For GOV1:
- Either EVL (if technically feasible) or cyanoacrylate glue injection are recommended endoscopic treatments. 1
- EVL showed initial hemostasis rates of 80-90% and rebleeding rates of 14-56% in GOV1 patients. 1
- The key is that GOV1 varices are small enough that both walls can be adequately suctioned into the ligator. 1
Critical Pitfalls to Avoid
Never attempt EVL on large fundal varices simply because the equipment is available. The technical failure will create a worse situation than the original varix. 1
Do not assume all gastric varices can be treated the same way. Sarin's classification exists precisely because GOV1, GOV2, and IGV1 require different management approaches. 1
If EVL is attempted on a fundal varix and the band falls off, recognize this as a medical emergency requiring immediate alternative therapy (TIPS or cyanoacrylate), as catastrophic rebleeding from the ulcer is highly likely. 1
In centers without cyanoacrylate expertise or TIPS capability, patients with fundal varices should be transferred to tertiary centers rather than attempting EVL. 1