A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices

Abstract 

Gastric varices (GV) occur in 20% of patients with portal hypertension either in isolation or in combination with esophageal varices (EV). There is no consensus for optimum treatment of GV and because they comprise an inhomogenous entity, accurate classification is vital to determine the appropriate management. Gastroesophageal varices (GOV) are classified as GOV1 (EV extending down to cardia or lesser curve) or GOV2 (esophageal and fundal varices). Isolated gastric varices (IGV) may be located in the fundus (IGV1) or elsewhere in the stomach (IGV2). GV possibly bleed less frequently than EV, but GV bleeding is typically difficult to control, associated with a high risk for rebleeding, and high mortality. Fundal varices, large GV (>5 mm), presence of a red spot, and Child’s C liver status are associated with a high risk for bleeding. GOV1 have a much lower risk for bleeding. A portosystemic pressure gradient of ≥12 mm Hg is not necessary for GV bleeding, probably related to the high frequency of spontaneous gastrorenal shunts in these patients. GOV1 should be treated as for EV. First-line treatment of bleeding fundal varices is endoscopic variceal obturation. TIPS is currently second-line acute treatment and is used for prevention of rebleeding. The role of some newer interventional radiologic techniques requires further appraisal. This review describes the pathophysiology, diagnosis, natural history, endoscopic, and interventional radiologic treatment options for GV.

Abbreviations:  B-RTO, balloon occluded retrograde transvenous occlusion, EV, esophageal varices, EVL, endoscopic variceal ligation, EVO, endoscopic variceal obturation, EVS, endoscopic variceal sclerotherapy, GOV, gastroesophageal varices, GRS, gastrorenal shunt, GV, gastric varices, IGV, isolated gastric varices, PHT, portal hypertension, PPG, portosystemic pressure gradient, RCT, randomized controlled trial, TIPS, transjugular intrahepatic portosystemic shunt