Approach to a patient with

Gastric varices
By: Dr. Deepanshu khanna
DrNB Resident Gastroenterology
Introduction
• Gastric varices (GV) are a bunch of vessels in the mucosa/submucosa of the
stomach and part of a complex collection of vascular shunts between the
portal and systemic circulation.
• The prevalence of GV with portal hypertension ranges from 17% to 25% as
compared with 85% for esophageal varices(EV).
• The incidence of GV varies from 16% at 1 year to 44% at 5 years.
• In the setting of cirrhosis and portal hypertension, GV may be seen in 20%
of patients with EV, often owing to elevated splenic venous pressures.
• Sometimes isolated GV may be seen with portal vein occlusion in the
absence of cirrhosis.
• GV can bleed at low pressures and the bleeding is generally intense with
higher rates of blood transfusion, uncontrolled bleeding, rebleeding, and
death.
• Unlike EV, bleeding from GV is more related to their size, wall thickness,
and the presence of red color signs.
• Treatment options for GV bleeding include pharmacological therapy,
endoscopic cyanoacrylate glue injection (ECI), and endovascular
intervention.
• Although ECI is relatively easy to perform and effective, owing to the
complex nature of shunts and collateral pathways, endovascular
procedures like balloon retrograde transvenous obliteration (BRTO), plug-
assisted retrograde transvenous obliteration (PARTO), or coil-assisted
retrograde transvenous obliteration is advocated for effective therapy.
Classification of GV Based on Endoscopy
• Sarin classification(Most widely used) -endoscopic classification based on the anatomical
location of varix as seen on endoscopy.
• It diffrentiates Gastroesophageal varices (GOV) from isolated GV (IGV).
• GOV: Type 1 (GOV1 seen in 70% of GV) found along the lesser curvature and the cardia
Type 2(GOV2) are predominantly along the gastric fundus and may extend to the cardia.
• IGV: IGV type 1 located in the fundus
IGV type 2 are distal GV or those located at other sporadic locations.
• For all practical purposes, true GV or cardiofundal varices are the GOV2 and IGV1 of the Sarin’s
classification.
• GOV1 varices are treated like EV with traditional endoscopic techniques.
• Cardiofundal varices (GOV2 and IGV1), however, require a meticulous pretreatment planning to
achieve a reliable and sustained result of therapy.
Classification of GV Based on Crosssectional
Radiologic Imaging
• Triphasic computed tomography (CT) pictorial classification is based on the afferent and
efferent vascular hemodynamic pattern to identify the presence or absence of inflow and
outflow channels that could be mapped to plan an effective therapy.
• Type B (Kiyosue classification), in which there is a prominent gastrorenal or gastro–short
gastric collateral is seen across most of the patients with cardio-fundal varices.
• A more practical classification also based on CT scan was described by Saad et al,
combining both the inflow and outflow collaterals.
• The type IIb, in which the afferent channels are the posterior gastric vein/short gastric
veins and the efferent is the gastrorenal shunt is most seen in clinical practice.
• The purpose of these radiologic classifications is to ascertain the presence and nature of
the inflow and outflow collaterals in the GV collateral complex to plan a better and
sustained therapeutic approach.
Presentation
GV can present in three clinical settings:
1. Actively bleeding GV (urgent treatment)
2. Elective treatment of GV with a history of bleeding(secondary
prophylaxis)
3. Incidentally detected GV with no history of bleeding.(primary
prophylaxis)
Treatment Based on Presentation
• Actively Bleeding GV (Urgent Treatment).
• A patient with actively bleeding GVs needs to be primarily optimized
and resuscitated.
• This includes airway protection, fluid resuscitation, antibiotic
prophylaxis, and judicious transfusion of platelets and packed red
blood cells to target hemoglobin of 7–8 g/dL for hemodynamic
stabilization.
• There are few data on the effectiveness of administering vasoactive
medications like terlipressin, vasopressin, somatostatin, or octreotide
in bleeding GV.
• An urgent endoscopy is usually advocated to achieve immediate control of
acute bleeding.
• Endoscopic cyanoacrylate injection is presently recommended as the first
line of therapy as per the Baveno VI criteria, the American Association for
the study of liver diseases guidelines, and the European Society of
Gastrointestinal Endoscopy Cascade Guidelines.
• With an ECI >90%, hemostasis rates have been achieved, with 70%–90% of
variceal obliteration and depends upon the technique and experience of
the endoscopist.
• Because bleeding from GV is usually profuse, the use of a larger channel
endoscope, double-channel endoscope, and changing the patients’
position(head high, supine, right lateral) during the procedure can be
helpful. Clots can be cleared by morcellating them using a dormia basket.
Elective Treatment of GV With a History of
Bleeding (Secondary Prophylaxis)
• ECI has been shown to effectively obliterate GV in the elective setting with
a significantly low rate of rebleeding (<30%).
• However, severe adverse events like fatal embolization into the systemic
circulation.
• This has prompted endoscopists to perform endoscopic ultrasound (EUS)-
guided therapy like the injection of coils alone or coils with ECI, this
practice has been shown to eradicate GV in 96% of patients in a single
sitting, with minimal adverse events and a 6-month rebleed rate of 16%.
• A systematic review and meta-analysis also preferred EUS combination
therapy (coil embolization with ECI) over EUS-based monotherapy.
• However, EUS-guided therapies have not been directly compared with a
standardized ECI.
• After the effective obliteration of GV with ECI or with EUS-guided
therapy, these patients are followed at 1 month to assess continued
variceal obliteration and then every 4 months until the solidified
cyanoacrylate extrudes out of the obliterated GV and leads to scar
formation at that site.
• For those patients who develop recurrent bleeding despite effective
obliteration, cross-sectional imaging is carried out to assess the inflow
and outflow veins in the GV complex.
• If large high-volume shunts are noticed, additional endovascular
therapy is adopted to block these efferent channels with the help of
interventional radiology
Incidentally Detected GV With no History of
Bleeding (Primary Prophylaxis)
• In patients with GV who have not bled, the Baveno VI consensus recommends the
use of nonselective beta-blockers.
• The role of ECI in primary prophylaxis is unclear; however, in an Indian study, ECI
was found to have low bleeding and mortality compared with nonselective beta-
blockers.
• Prophylactic ECI was efficacious in patients with high-risk GV with good short-
term survival.
• EUS-guided interventions have also been described by Bhat et al for primary
prophylaxis of GV with rebleeding rates of <5%.
• It is recommended that prophylactic ECI for patients of large GV with a thin wall,
red spots, poor liver function, or those who cannot avail of urgent expert medical
care in case of acute bleeding.
• Further advantages of a EUS-guided therapy include realtime Doppler assessment
of the GV complex and its feeding channels.
The Technique of ECI
• Which Cyanoacrylate Is Ideal and How Does It Work?
➢Acrylic resin monomers
➢Undergo rapid chain polymerization when they come in contact with
hydroxide ions.
➢liquid monomer forms long strong solid chains after polymerization
and thereby obliterates the vessel containing blood.
➢Reaction is exothermic, which further damages the vessel intima.
➢n-butyl-2 cyanoacrylate is the most commonly used
Changing Concepts of Approaching a
Patient With GV
• Cross-sectional radiologic assessment has shown that GV seen on
endoscopy are only a visible part of a complex collection of shunts
between the portal and systemic circulation in the majority of the patients.
• What is seen during endoscopy is only the tip of an iceberg with complex
inflow and outflow channels beyond the stomach wall.
• Although the treatment of acute GV bleeding can be achieved effectively
with ECI, for a better long-term bleed-free interval and to prevent a
recurrence, one needs to identify the abnormal portosystemic shunts with
a triphasic CT scan.
• Radiologic studies have classified GV into various types based on the
afferent or efferent venous shunts or a combination of both (Kiyosue and
Saad Caldwell classifications).
• Based on these radiologic classifications, radiologists have been
treating GV with a variety of methods like BRTO, PARTO, coil-assisted
retrograde transvenous obliteration, or transjugular intrahepatic
portosystemic shunt (TIPS).
• BRTO is time consuming and associated with complications.
• Therefore, radiologists now consider PARTO to be a more efficient and
faster method of treatment.
• PARTO is a modified BRTO procedure that employs vascular plugs for
obliteration of the spontaneous portosystemic shunts (SPSS) and has
shown 98.6% obliteration of GV or SPSS.
• The rate of complications after liver transplantation (LT) increases in patients with low
portal venous flow, portal vein thrombosis or large SPSS.
• PARTO or intraoperative ligation of SPSS helps prevent complications after LT in such
patients
• If no efferent shunts are found on imaging, only ECI should be continued on follow-up if
the GV persists.
• If efferent shunts are found, the patency of the PV decides further therapy.
• If the portal vein is blocked and associated with hepatic encephalopathy (HE), only ECI
should be considered as the treatment of choice.
• In the absence of HE, BRTO or PARTO should be considered with TIPS to prevent the
rapid development of ascites.
• If the portal vein is patent and there is no evidence of any ascites, HE, or EV then the
treatment can be augmented using either BRTO or PARTO. But if there is the presence of
ascites or HE either a TIPS should be added or treated only with ECI.