Does endoscopic variceal ligation (EVL) of esophageal varices increase the risk of bleeding from fundal varices in patients with a history of liver disease?

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

EVL of esophageal varices does not directly increase the risk of bleeding from fundal varices; however, when esophageal varices are eradicated, gastric varices (particularly GOV1) may subsequently disappear in 65% of cases, while the remaining 35% may persist with a rebleeding rate of 16-42%. 1

Understanding the Relationship Between Esophageal and Gastric Varices

GOV1 Varices (Lesser Curvature Extension)

• GOV1 varices extending along the lesser curvature can be managed similarly to esophageal varices, as they often resolve when esophageal varices are controlled with EVL 1
• When concurrent esophageal varices are eradicated with EVL, gastric varices subsequently disappeared in 65% of patients 1
• The rebleeding rate from GOV1s following eradication of esophageal varices ranges from 16-42% 1
• Esophageal EVL can be performed simultaneously with or after treatments for gastric varices 1

GOV2 and IGV1 Varices (Fundal Varices)

• EVL should be avoided in patients with fundal varices (GOV2 and IGV1) due to significantly increased risk of catastrophic bleeding 2
• 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, 2
• The gastric mucosa is significantly thicker than esophageal mucosa, making adequate ligation technically difficult or impossible 2
• Fundal varices are typically too large and deep for safe ligation, as EVL should only be performed when both the mucosal and contralateral wall can be adequately suctioned into the ligator 2

Clinical Algorithm for Managing Concurrent Esophageal and Gastric Varices

Step 1: Classify the Gastric Varices

• GOV1 (lesser curvature): Treat esophageal varices with EVL; gastric varices may resolve spontaneously 1
• GOV2/IGV1 (fundal): Use EVO, TIPS, or BRTO instead of EVL 1, 2

Step 2: Treatment Sequence

• For GOV1 with medium-to-large esophageal varices: Perform EVL of esophageal varices with concurrent NSBB therapy 1
• For GOV2/IGV1: Treat fundal varices first with EVO (hemostasis rate 91-97%), then address esophageal varices according to standard guidelines 1
• Treatment of accompanying esophageal varices can be performed with or after treatment of fundic varices 1

Step 3: Monitor for Persistent Gastric Varices

• After esophageal variceal eradication, reassess for persistent GOV1 at surveillance endoscopy 1
• If GOV1 persists after esophageal variceal eradication, perform repeated EVO or EVL 1
• For persistent GOV2/IGV1, use EVO or retrograde transvenous obliteration (BRTO/PARTO) 1

Critical Pitfalls to Avoid

Never Attempt EVL on Large Fundal Varices

• Do not attempt EVL on large fundal varices simply because the equipment is available, as technical failure creates a worse situation than the original varix 2
• If EVL is attempted on a fundal varix and the band falls off, this creates gastric ulcers that expose submucosal varices directly to gastric acid, potentially causing massive bleeding 1, 2
• Recognize failed EVL on fundal varices as a medical emergency requiring immediate alternative therapy (TIPS or cyanoacrylate) 2

Distinguish Between Gastric Varix Types

• 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 2
• GOV1 behaves more like esophageal varices and can be treated with EVL 1, 3
• GOV2 and IGV1 require cyanoacrylate injection, TIPS, or BRTO as first-line therapy 1, 3

Evidence Quality Considerations

• The Korean Association for the Study of the Liver (KASL) 2020 guidelines provide the most comprehensive algorithmic approach to managing concurrent esophageal and gastric varices 1
• The European Society of Gastrointestinal Endoscopy (ESGE) 2022 guidelines strongly recommend endoscopic cyanoacrylate injection for GOV2/IGV1 hemorrhage and either cyanoacrylate or EBL for GOV1-specific bleeding 3
• The evidence consistently shows that EVL of esophageal varices does not increase fundal variceal bleeding risk, but rather may reduce it by decreasing overall portal pressure 1, 4