Grading of Gastric Varices
Gastric varices are classified based on their anatomic location and relationship to esophageal varices using the Sarin classification system, which divides them into gastroesophageal varices (GOV1 and GOV2) and isolated gastric varices (IGV1 and IGV2). 1
Standard Classification System
The Sarin classification is the most widely accepted grading system for gastric varices, based on anatomic location and relationship to esophageal varices 1:
Gastroesophageal Varices (GOV)
- GOV1: Varices extending from the esophagus along the lesser curvature of the stomach 1
- GOV2: Varices extending from the esophagus toward the gastric fundus 1
- Higher bleeding risk than GOV1 1
Isolated Gastric Varices (IGV)
- IGV1: Varices located in the gastric fundus without esophageal varices 1
- Highest bleeding risk among all gastric variceal types 1
- IGV2: Varices located in other regions of the stomach (body, antrum) or duodenum 1
- Rare, often associated with splenic vein thrombosis 1
Alternative Simplified Classification
A more intuitive classification system has been proposed by the American Gastroenterological Association 1:
- Cardiofundal GV: Varices on the posterior and/or greater curvature side of the cardia (analogous to GOV2 and IGV1)
- Lesser curve GV: Varices on the lesser curve of the cardia (analogous to GOV1)
- Distal GV: Rare varices in the gastric body and distal stomach (analogous to IGV2)
Additional Risk Stratification Parameters
Beyond anatomic classification, several endoscopic features predict bleeding risk 1, 2:
Size Grading
- Small: <5 mm diameter
- Large: >5 mm diameter 3
- Larger varices (>10 mm) have significantly higher bleeding risk 1
Red Color Signs
- Red color spots (RC spots): Glossy, thin-walled focal redness on the varix 2
- Presence of red color signs independently predicts bleeding 1, 2
Form Classification (Japanese system) 2
- F1 (Tortuous): Serpentine appearance
- F2 (Nodular): Beaded appearance
- F3 (Tumorous): Large, bulging appearance
- F2 form is an independent risk factor for bleeding 2
Clinical Significance by Type
Bleeding risk hierarchy: IGV1 > GOV2 > GOV1 1
- GOV1 bleeds less frequently (similar to esophageal varices) and often resolves with treatment of esophageal varices 1, 4
- GOV2 and IGV1 have higher bleeding rates, more severe bleeding episodes, and higher mortality 1, 3
- Gastric varices overall bleed less frequently than esophageal varices (25% vs 64% over 2 years) but with greater severity and higher mortality when bleeding occurs 1, 5
Key Clinical Pearls
- Always obtain cross-sectional imaging (CT or MRI with portal venous phase) before definitive treatment to assess vascular anatomy, identify splenic vein thrombosis, and plan appropriate therapy 1
- IGV2 associated with splenic vein thrombosis may require splenectomy rather than endoscopic or radiologic intervention 1
- The classification system directly guides treatment strategy: GOV1 is managed like esophageal varices, while GOV2 and IGV1 require different approaches (cyanoacrylate injection, BRTO, or TIPS) 1