From the Guidelines
GAVE treatment should prioritize endoscopic cyanoacrylate injection (ECI) as the definitive therapy for bleeding gastric varices, particularly for cardiofundal varices, due to its effectiveness in preventing rebleeding and minimizing complications. The choice of cyanoacrylate formulation is crucial, with 4 carbon (butyl) preparations preferred over 8 carbon (octyl) preparations due to their faster polymerization time, which reduces the risk of embolization 1.
Key Considerations for GAVE Treatment
- ECI is the recommended definitive endoscopic therapy for cardiofundal gastric varices, given its superiority in preventing rebleeding and its lower complication rate compared to other endoscopic methods like band ligation 1.
- For lesser curve gastric varices, which often extend from esophageal varices, band ligation can be an effective treatment option, especially when the vascular anatomy is similar to that of esophageal varices 1.
- The use of plant-based oils like lipiodol with cyanoacrylate for injection is not recommended due to the unnecessary risk of distal embolization and the lack of need for radiographic confirmation of success 1.
- Following definitive endoscopic treatment with cyanoacrylate injection, regular endoscopic follow-ups are necessary to assess the need for repeat injections and to monitor for complications or recurrence 2.
Multidisciplinary Approach
A collaborative approach involving gastroenterologists, hepatologists, and interventional radiologists is essential for the management of bleeding gastric varices, ensuring that patients receive comprehensive care tailored to their specific needs and vascular anatomy 2. This approach allows for the consideration of various treatment options, including endoscopic therapies, transjugular intrahepatic portosystemic shunt (TIPS) placement, and balloon-occluded retrograde transvenous obliteration (BRTO), based on the patient's underlying condition and the presence of portosystemic shunts or other complications 2.
From the Research
GAVE Treatment Options
- Endoscopic argon plasma coagulation (APC) is a safe and effective treatment for gastric antral vascular ectasia (GAVE), with a sustained increase in mean haemoglobin levels and a significant decrease in transfusion requirements 3, 4.
- Other endoscopic treatments for GAVE include radiofrequency ablation (RFA) and endoscopic band ligation (EBL), which have shown efficacy and safety in various studies 5, 6.
- Pharmacotherapy is also an option for GAVE treatment, with various drugs such as octreotide, cyproheptadine, and tranexamic acid being used, although the evidence is limited to scattered case reports or small case series 7.
- Surgery may be considered in cases where conservative treatment is ineffective, but it is invasive and carries a relatively high risk of postoperative complications 7, 5.
Efficacy and Safety of Endoscopic Treatments
- Argon plasma coagulation (APC) has an endoscopic success rate of 40-100%, but requires several treatment sessions and has a high recurrence rate of 10-78.9% 5.
- Radiofrequency ablation (RFA) and endoscopic band ligation (EBL) have endoscopic success rates of 90-100% and 77.8-100%, respectively, with recurrence rates of 21.4-33.3% and 8.3-48.1%, respectively 5.
- Adverse events associated with endoscopic treatments for GAVE include hyperplastic gastric polyps, sepsis, Mallory-Weiss syndrome, nausea, vomiting, esophageal or abdominal pain, and hyperplastic polyps 5, 4.