ABSTRACT
In the past 20 years, our understanding of the pathophysiology and management options
among patients with gastric varices (GV) has changed significantly. GV are the most
common cause of upper gastrointestinal bleeding in patients with portal hypertension
after esophageal varices (EV) and generally have more severe bleeding than EV. In
the United States, the majority of GV patients have underlying portal hypertension
rather than splenic vein thrombosis. The widely used classifications are the Sarin
Endoscopic Classification and the Japanese Vascular Classifications. The former is
based on the endoscopic appearance and location of the varices, while the Japanese
classification is based on the underlying vascular anatomy. In this article, the authors
address the current concepts of classification, epidemiology, pathophysiology, and
emerging management options of gastric varices. They describe the stepwise approach
to patients with gastric varices, including the different available modalities, and
the pearls, pitfalls, and stop-gap measures useful in managing patients with gastric
variceal bleed.
KEYWORDS
Gastric varices - portal hypertension - liver cirrhosis - BRTO - TIPS - splenorenal
shunt - cyanoacrylate
REFERENCES
- 1
Sarin S K, Kumar A.
Gastric varices: profile, classification, and management.
Am J Gastroenterol.
1989;
84
(10)
1244-1249
- 2
Stray N, Jacobsen C D, Rosseland A.
Injection sclerotherapy of bleeding oesophageal and gastric varices using a flexible
endoscope.
Acta Med Scand.
1982;
211
(1-2)
125-129
- 3
Sarin S K, Lahoti D, Saxena S P, Murthy N S, Makwana U K.
Prevalence, classification and natural history of gastric varices: a long-term follow-up
study in 568 portal hypertension patients.
Hepatology.
1992;
16
(6)
1343-1349
- 4
Caldwell S H, Hespenheide E E, Greenwald B D, Northup P G, Patrie J T.
Enbucrilate for gastric varices: extended experience in 92 patients.
Aliment Pharmacol Ther.
2007;
26
(1)
49-59
- 5
Arakawa M, Masuzaki T, Okuda K.
Pathology of fundic varices of the stomach and rupture.
J Gastroenterol Hepatol.
2002;
17
(10)
1064-1069
- 6
Agarwal A K, Raj Kumar K, Agarwal S, Singh S.
Significance of splenic vein thrombosis in chronic pancreatitis.
Am J Surg.
2008;
196
(2)
149-154
- 7
Heider T R, Azeem S, Galanko J A, Behrns K E.
The natural history of pancreatitis-induced splenic vein thrombosis.
Ann Surg.
2004;
239
(6)
876-880
discussion 880-882
- 8
Ryan B M, Stockbrugger R W, Ryan J M.
A pathophysiologic, gastroenterologic, and radiologic approach to the management of
gastric varices.
Gastroenterology.
2004;
126
(4)
1175-1189
- 9
Trudeau W, Prindiville T.
Endoscopic injection sclerosis in bleeding gastric varices.
Gastrointest Endosc.
1986;
32
(4)
264-268
- 10
Chey W D, Elta G H.
Natural history of gastric varices.
Gastroenterology.
1993;
105
(2)
599-602
- 11
Kim T, Shijo H, Kokawa H et al..
Risk factors for hemorrhage from gastric fundal varices.
Hepatology.
1997;
25
(2)
307-312
- 12
Sarin S K.
Long-term follow-up of gastric variceal sclerotherapy: an eleven-year experience.
Gastrointest Endosc.
1997;
46
(1)
8-14
- 13
Jutabha R, Jensen D M, Kovacs T OG et al..
Initial results of combination banding and sclerotherapy compared to sclerotherapy
alone for bleeding gastric varices.
Gastrointest Endosc.
1998;
47
AB86
- 14
Scapa E.
Treating gastrointestinal bleeding with endoscopic hemoclips.
Surg Laparosc Endosc.
1997;
7
(2)
94-96
- 15
Kravetz D, Bosch J, Arderiu M, Pilar Pizcueta M, Rodés J.
Hemodynamic effects of blood volume restitution following a hemorrhage in rats with
portal hypertension due to cirrhosis of the liver: influence of the extent of portal-systemic
shunting.
Hepatology.
1989;
9
(6)
808-814
- 16
Castañeda B, Morales J, Lionetti R et al..
Effects of blood volume restitution following a portal hypertensive-related bleeding
in anesthetized cirrhotic rats.
Hepatology.
2001;
33
(4)
821-825
- 17
Villanueva C, Ortiz J, Miñana J et al..
Somatostatin treatment and risk stratification by continuous portal pressure monitoring
during acute variceal bleeding.
Gastroenterology.
2001;
121
(1)
110-117
- 18
de Franchis R.
Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop
on methodology of diagnosis and therapy in portal hypertension.
J Hepatol.
2005;
43
(1)
167-176
- 19
Gabriel D A, Li X, Monroe III DMIII, Roberts H R.
Recombinant human factor VIIa (rFVIIa) can activate factor FIX on activated platelets.
J Thromb Haemost.
2004;
2
(10)
1816-1822
- 20
Porte R J, Molenaar I Q, Begliomini B EMSALT Study Group et al.
Aprotinin and transfusion requirements in orthotopic liver transplantation: a multicentre
randomised double-blind study.
Lancet.
2000;
355
(9212)
1303-1309
- 21
Westerkamp A C, Lisman T, Porte R J.
How to minimize blood loss during liver surgery in patients with cirrhosis.
HPB (Oxford).
2009;
11
(6)
453-458
- 22
Youssef W I, Salazar F D, Dasarathy S, Beddow T, Mullen K D.
Role of fresh frozen plasma infusion in correction of coagulopathy of chronic liver
disease: a dual phase study.
Am J Gastroenterol.
2003;
98
(6)
1391-1394
- 23
Porte R J, Lisman T, Tripodi A, Caldwell S H, Trotter J F. Coagulation in Liver Disease
Study Group .
The international normalized ratio (INR) in the MELD score: problems and solutions.
Am J Transplant.
2010;
10
(6)
1349-1353
- 24
Trotter J F, Olson J, Lefkowitz J, Smith A D, Arjal R, Kenison J.
Changes in international normalized ratio (INR) and model for endstage liver disease
(MELD) based on selection of clinical laboratory.
Am J Transplant.
2007;
7
(6)
1624-1628
- 25
Tripodi A, Primignani M, Chantarangkul V et al..
Thrombin generation in patients with cirrhosis: the role of platelets.
Hepatology.
2006;
44
(2)
440-445
- 26
Hou M C, Lin H C, Kuo B I, Lee F Y, Schmidt C M, Lee S D.
Clinical implications of the white nipple sign and its role in the diagnosis of esophageal
variceal hemorrhage.
Am J Gastroenterol.
1996;
91
(10)
2103-2109
- 27
Bosch J, Thabut D, Albillos A International Study Group on rFVIIa in UGI Hemorrhage
et al.
Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis:
a randomized, controlled trial.
Hepatology.
2008;
47
(5)
1604-1614
- 28
de Franchis R, Arcidiacono P G, Carpinelli L et al..
Randomized controlled trial of desmopressin plus terlipressin vs. terlipressin alone
for the treatment of acute variceal hemorrhage in cirrhotic patients: a multicenter,
double-blind study. New Italian Endoscopic Club.
Hepatology.
1993;
18
(5)
1102-1107
- 29
Sanyal A J, Freedman A M, Luketic V A et al..
Transjugular intrahepatic portosystemic shunts compared with endoscopic sclerotherapy
for the prevention of recurrent variceal hemorrhage. A randomized, controlled trial.
Ann Intern Med.
1997;
126
(11)
849-857
- 30
Barange K, Péron J M, Imani K et al..
Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding
from ruptured gastric varices.
Hepatology.
1999;
30
(5)
1139-1143
- 31
Tripathi D, Therapondos G, Jackson E, Redhead D N, Hayes P C.
The role of the transjugular intrahepatic portosystemic stent shunt (TIPSS) in the
management of bleeding gastric varices: clinical and haemodynamic correlations.
Gut.
2002;
51
(2)
270-274
- 32
Henderson J M, Boyer T D, Kutner M H DIVERT Study Group et al.
Distal splenorenal shunt versus transjugular intrahepatic portal systematic shunt
for variceal bleeding: a randomized trial.
Gastroenterology.
2006;
130
(6)
1643-1651
- 33
Ferral H, Gamboa P, Postoak D W et al..
Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction
with model for end-stage liver disease score.
Radiology.
2004;
231
(1)
231-236
- 34
Soehendra N, Grimm H, Nam V C, Berger B.
N-butyl-2-cyanoacrylate: a supplement to endoscopic sclerotherapy.
Endoscopy.
1987;
19
(6)
221-224
- 35
Rengstorff D S, Binmoeller K F.
A pilot study of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices
in humans.
Gastrointest Endosc.
2004;
59
(4)
553-558
- 36
Tan P C, Hou M C, Lin H C et al..
A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-butyl-2-cyanoacrylate
injection versus band ligation.
Hepatology.
2006;
43
(4)
690-697
- 37
Lo G H, Lai K H, Cheng J S, Chen M H, Chiang H T.
A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation
in the management of bleeding gastric varices.
Hepatology.
2001;
33
(5)
1060-1064
- 38
Mahadeva S, Bellamy M C, Kessel D, Davies M H, Millson C E.
Cost-effectiveness of N-butyl-2-cyanoacrylate (histoacryl) glue injections versus
transjugular intrahepatic portosystemic shunt in the management of acute gastric variceal
bleeding.
Am J Gastroenterol.
2003;
98
(12)
2688-2693
- 39
Greenwald B D, Caldwell S H, Hespenheide E E et al..
N-2-butyl-cyanoacrylate for bleeding gastric varices: a United States pilot study
and cost analysis.
Am J Gastroenterol.
2003;
98
(9)
1982-1988
- 40
Procaccini N J, Al-Osaimi A M, Northup P, Argo C, Caldwell S H.
Endoscopic cyanoacrylate versus transjugular intrahepatic portosystemic shunt for
gastric variceal bleeding: a single-center U.S. analysis.
Gastrointest Endosc.
2009;
70
(5)
881-887
- 41
Lo G H, Liang H L, Chen W C et al..
A prospective, randomized controlled trial of transjugular intrahepatic portosystemic
shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding.
Endoscopy.
2007;
39
(8)
679-685
- 42
Williams S G, Peters R A, Westaby D.
Thrombin—an effective treatment for gastric variceal haemorrhage.
Gut.
1994;
35
(9)
1287-1289
- 43
Przemioslo R T, McNair A, Williams R.
Thrombin is effective in arresting bleeding from gastric variceal hemorrhage.
Dig Dis Sci.
1999;
44
(4)
778-781
- 44
Yang W L, Tripathi D, Therapondos G, Todd A, Hayes P C.
Endoscopic use of human thrombin in bleeding gastric varices.
Am J Gastroenterol.
2002;
97
(6)
1381-1385
- 45
Ramesh J, Limdi J K, Sharma V, Makin A J.
The use of thrombin injections in the management of bleeding gastric varices: a single-center
experience.
Gastrointest Endosc.
2008;
68
(5)
877-882
- 46
Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K.
Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration.
J Gastroenterol Hepatol.
1996;
11
(1)
51-58
- 47
Matsumoto A, Hamamoto N, Nomura T et al..
Balloon-occluded retrograde transvenous obliteration of high risk gastric fundal varices.
Am J Gastroenterol.
1999;
94
(3)
643-649
- 48
Tanihata H, Minamiguchi H, Sato M et al..
Changes in portal systemic pressure gradient after balloon-occluded retrograde transvenous
obliteration of gastric varices and aggravation of esophageal varices.
Cardiovasc Intervent Radiol.
2009;
32
(6)
1209-1216
- 49
Cho S K, Shin S W, Do Y S et al..
Development of thrombus in the major systemic and portal veins after balloon-occluded
retrograde transvenous obliteration for treating gastric variceal bleeding: its frequency
and outcome evaluation with CT.
J Vasc Interv Radiol.
2008;
19
(4)
529-538
- 50
Cho S K, Shin S W, Yoo E Y et al..
The short-term effects of balloon-occluded retrograde transvenous obliteration, for
treating gastric variceal bleeding, on portal hypertensive changes: a CT evaluation.
Korean J Radiol.
2007;
8
(6)
520-530
- 51
Sabri S S, Swee W, Turba U C et al..
Bleeding gastric varices obliteration with balloon-occluded retrograde transvenous
obliteration using sodium tetradecyl sulfate foam.
J Vasc Interv Radiol.
2011;
22
(3)
309-316
quiz 316
- 52
Sarin S K, Mishra S R.
Endoscopic therapy for gastric varices.
Clin Liver Dis.
2010;
14
(2)
263-279
- 53
Irani S, Kowdley K, Kozarek R.
Gastric varices: an updated review of management.
J Clin Gastroenterol.
2011;
45
(2)
133-148
- 54
Sakurabayashi S, Sezai S, Yamamoto Y, Hirano M, Oka H.
Embolization of portal-systemic shunts in cirrhotic patients with chronic recurrent
hepatic encephalopathy.
Cardiovasc Intervent Radiol.
1997;
20
(2)
120-124
- 55
Fukuda T, Hirota S, Sugimura K.
Long-term results of balloon-occluded retrograde transvenous obliteration for the
treatment of gastric varices and hepatic encephalopathy.
J Vasc Interv Radiol.
2001;
12
(3)
327-336
Abdullah M. S. Al-OsaimiM.D. F.A.C.P. F.A.C.G. A.G.A.F.
Associate Professor of Medicine and Surgery, Medical Director of Liver Transplantation,
Division of Gastroenterology and Hepatology, Deparment of Medicine, University of
Virginia Health System
P.O. Box 800708, Charlottesville, VA 22908-0708
eMail: aa6h@virginia.edu
