Gastric varices

Gastric varices are dilated submucosal gastric veins that develop due to portal hypertension, most often from cirrhosis or splenic vein thrombosis. Although they are less common than esophageal varices, bleeding from gastric varices tends to be more severe and associated with higher rebleeding risk and mortality. Gastric varices are classified based on their anatomical location and association with esophageal varices. Diagnosis is made on esophagogastroduodenoscopy (EGD); cross-sectional imaging (e.g., CT or MRI with portal venous contrast phase) helps assess the portosystemic collateral anatomy and evaluate for thrombosis. Patients with acute gastric variceal bleeding require hemodynamic stabilization, vasoactive agents, antibiotic prophylaxis, and endoscopic treatment. Definitive management targets the underlying cause of portal hypertension.

• Incidence: ∼ 20% of individuals with portal hypertension ^[1]

Epidemiological data refers to the US, unless otherwise specified.

• Gastric varices arise in various conditions that cause portal hypertension. ^[2]
• Causes of left-sided portal hypertension (e.g., splenic vein thrombosis) usually lead to isolated gastric varices.

Gastric varices are classified according to the Sarin classification system based on their anatomical location. ^[3][4]

• Gastroesophageal varices: esophageal varices that extend beyond the gastroesophageal junction
  • Type 1 (75% of gastric varices): extension along the lesser curvature ^[4]
  • Type 2: extension along the greater curvature into the gastric fundus
• Isolated gastric varices (∼ 6% of gastric varices) ^[4]
  • Type 1: varices limited to the gastric fundus
  • Type 2: varices outside of the gastric fundus (i.e., in the antrum, corpus, and/or pylorus)

• Clinical features of portal hypertension and of the underlying cause of portal hypertension
• Features of bleeding varices, e.g.:
  • Features of overt GI bleeding (e.g., hematemesis, melena)
  • Features of anemia
  • Features of hemorrhagic shock

EGD ^[2][5]

• Indications: all patients with suspected gastric varices (e.g., those with portal hypertension, upper GI bleeding)
• Determines the location and size of gastric varices
• Evaluates for high-risk features for esophageal variceal hemorrhage (e.g., diameter > 10 mm, red wale marks) ^[2]

Cross-sectional imaging ^[2][5][6]

• Modalities: CT or MRI with portal venous contrast phase
• Indications: all patients, especially if endovascular treatment is planned
• Findings
  • Possible portosystemic collaterals (e.g., splenorenal, retrogastric)
  • Possible vascular thrombosis (e.g., portal vein thrombosis or splenic vein thrombosis)

General principles ^[2]

• The following are indicated in all patients with gastric varices:
  • Management of the underlying cause of portal hypertension
  • Nonselective beta blockers (NSBBs), unless contraindicated
  • Management of other complications of portal hypertension (e.g., treatment of ascites, treatment of hepatic encephalopathy)
• If NSBBs are contraindicated, endoscopic treatment may be considered for nonbleeding cardiofundal varices with high-risk features for esophageal variceal hemorrhage.
• Bleeding gastric varices require:
  • Acute stabilization
  • Endoscopic and/or endovascular treatment based on Sarin classification

Bleeding gastric varices ^[2][7]

Initial management

Initial management of bleeding gastric varices is identical to the management of bleeding esophageal varices. ^[2]

• Stabilize the patient: See “Initial management of overt gastrointestinal bleeding.”
• Start vasoactive therapy (e.g., octreotide or vasopressin).
• Administer prophylactic antibiotics (e.g., ceftriaxone).
• Consult gastroenterology for endoscopic assessment and/or treatment:
  • As soon as possible for unstable patients
  • Within 12 hours for stable patients ^[2]

Endoscopic treatment ^[1][2]

• Endoscopic cyanoacrylate injection ^[2]
  • Preferred initial treatment for gastric varices.
  • Performed with or without endoscopic ultrasound-guided coil embolization
  • Treatment is repeated every 2–4 weeks until obliteration, with long-term follow-up. ^[2]
• Endoscopic variceal ligation: considered for
  • Gastroesophageal varices type 1
  • Gastroesophageal varices type 2 or isolated gastric varices type 1:
    • If no other options are available, the site of rupture is visible, and the varices can be suctioned entirely into the band ^[2]
    • Usually requires concomitant endovascular treatment

Endovascular treatment ^[1][2]

• Indications
  • Alternative option for gastroesophageal varices type 2 and isolated gastric varices type 1 and 2 ^[1]
  • Unsuccessful endoscopic treatment
• Procedures: The choice of procedure should involve a multidisciplinary team; comorbidities and other factors related to treatment success should be considered.
  • Transjugular intrahepatic portosystemic shunt (TIPS)
  • Balloon-occluded retrograde transvenous obliteration: if TIPS is contraindicated

• Bleeding occurs in ∼ 16–45% of patients with cardiofundal varices within 3 years. ^[2]
• Mortality from gastric variceal bleeding: 20–55% ^[1]

Overall prognosis is poorer for gastric varices than for esophageal varices because gastric variceal bleeding tends to be more severe and difficult to control.