Perspectives in clinical gastroenterology and hepatology
Management of Gastric Varices

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According to their location, gastric varices (GV) are classified as gastroesophageal varices and isolated gastric varices. This review will mainly focus on those GV located in the fundus of the stomach (isolated gastric varices 1 and gastroesophageal varices 2). The 1-year risk of GV bleeding has been reported to be around 10%-16%. Size of GV, presence of red signs, and the degree of liver dysfunction are independent predictors of bleeding. Limited data suggest that tissue adhesives, mainly cyanoacrylate (CA), may be effective and better than propranolol in preventing bleeding from GV. General management of acute GV bleeding must be similar to that of esophageal variceal bleeding, including prophylactic antibiotics, a careful replacement of volemia, and early administration of vasoactive drugs. Small sample-sized randomized controlled trials have shown that tissue adhesives are the therapy of choice for acute GV bleeding. In treatment failures, transjugular intrahepatic portosystemic shunt (TIPS) is considered the treatment of choice. After initial hemostasis, repeated sessions with CA injections along with nonselective beta-blockers are recommended as secondary prophylaxis; whether CA is superior to TIPS in this scenario is not completely clear. Balloon-occluded retrograde transvenous obliteration (BRTO) has been introduced as a new method to treat GV. BRTO is also effective and has the potential benefit of increasing portal hepatic blood flow and therefore may be an alternative for patients who may not tolerate TIPS. However, BRTO obliterates spontaneous portosystemic shunts, potentially aggravating portal hypertension and its related complications. The role of BRTO in the management of acute GV bleeding is promising but merits further evaluation.

Section snippets

Primary Prophylaxis

In a prospective study including 117 patients with cirrhosis and cardiofundal varices (69% IGV1 and 31% GOV2), the incidence of bleeding was 16%, 36%, and 44% at 1, 3, and 5 years, respectively. Size of varices, presence of red signs, and the degree of liver dysfunction were directly related with the risk of bleeding (ranging from an annual incidence of bleeding of 4% in patients with Child class A with small varices without red signs to 65% in patients with Child class C with large varices

Management of Acute Gastric Variceal Bleeding

Although no studies have been specifically devoted to address this issue in patients with cardiofundal varices, general consensus is that the initial management is similar to that of esophageal variceal bleeding, including the use of prophylactic antibiotics, careful replacement of volemia with a restrictive transfusion policy, and the early administration of vasoactive drugs (terlipressin, somatostatin, or a somatostatin analogue).4, 5 IGV1 varices, which often appear as a consequence of large

Secondary Prophylaxis

Rebleeding rates after an acute GV bleeding episode treated with tissue adhesives (mainly CA) range from 7%-65%, with most of the large series reporting rates below 15%. Thus, after initial hemostasis with tissue adhesives, repeated sessions are performed on a 2- to 4-week basis until endoscopic obliteration is achieved. Several case series and controlled studies have specifically evaluated the effect of long-term injections of tissue adhesives (mainly CA) to prevent GV rebleeding17, 25, 26, 27

Other Endoscopic Therapies

Other endoscopic treatments have also been used to prevent rebleeding. Sclerotherapy has been abandoned because of high rebleeding rates (50%-90%). Variceal band ligation may be used for those patients with GOV1 and in some cases of small GOV2, and it is generally performed every 2 weeks until apparent endoscopic obliteration. However, band ligation is limited by the fact that it cannot be used in large GOV2 or IGV1.7 Detachable loop snares to treat large GV (>2 cm) along with propranolol have

Thrombin

Thrombin converts fibrinogen to a fibrin clot, thus forming a clot inside the GV and occluding blood flow. The use of bovine thrombin was banned because of the risk of potential prion transmission. This is not the case when using commercially available human thrombin. Each vial is reconstituted with 5 mL distilled water for a concentration of 250 U/mL.35 The average dose of injected thrombin ranges between 1500 and 2000 U. Available data indicate that thrombin is safe and effective in the

Transjugular Intrahepatic Portosystemic Shunt

The role of TIPS vs CA in preventing GV bleeding has been evaluated in 3 small studies (2 retrospective observational studies and 1 prospective). Remarkably, in all 3 studies most patients included had GOV1, a few GOV2, and only anecdotal IGV1 varices. In addition, the stents used were uncoated, which has been shown to be associated with lower TIPS patency, efficacy, and survival than coated stents.42 Two of these studies23, 43 showed a higher rebleeding rate in the CA group (30% and 59%) vs

Surgery

Surgery has currently fallen out of favor for patients with portal hypertension because of the wide availability of less invasive techniques such as endoscopy and interventional radiology. In selected cases, patients with GV and segmental/left-sided portal hypertension that is due to isolated splenic vein thrombosis may be candidates for splenectomy or splenic embolization as a means of definitive therapy; however, data are scarce.

Balloon-occluded Retrograde Transvenous Obliteration

Balloon-occluded retrograde transvenous obliteration (BRTO) has been introduced as a treatment method that aims to directly obliterate the GV. Since its introduction by Kanagawa et al,45 BRTO has become widely accepted in Japan and in some centers in the United States as a minimally invasive and highly effective treatment for GV. The technical difficulty of BRTO relies on the anatomy of the afferent and draining veins of the GV. Accurate assessment, which is mainly based on imaging studies of

Summary

The best management strategy for GV has not been completely established because of a paucity of data of RCTs in this area. Specific treatments such as CA injection and BRTO are not widely available in all centers. Another limitation is the fact that tissue adhesives such as CA are not approved by the Food and Drug Administration in the United States, and thus, recommendations arising from published studies, guidelines, and expert opinion cannot be extrapolated to routine practice. We recommend

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      Citation Excerpt :

      However, our results showed that there was no interaction between the location of the varices and treatment group. A possible explanation might be that the most common gastric varices in our cohort were gastroesophageal varices type 1, a continuation of oesophageal varices into the lesser curvature of the stomach, in which gastrorenal and portosystemic shunts are less common.39 Other patients, such as those with continued variceal filling despite a patent shunt and those with large calibre submucosal vessels, might have a high-risk of rebleeding after TIPS and might benefit from embolisation.17

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    This article has an accompanying continuing medical education activity on page e52. Learning Objectives-At the end of this activity, the successful learner will understand the prevalence, classification, and therapy of gastric varices in patients with cirrhosis.

    Conflicts of interest These authors disclose the following: Juan Garcia-Pagán received grant support from GORE. Andres Cardenas has been a consultant to Limmedx LLC, Frontier Medex, and BMJ Publishing Group. The remaining authors disclose no conflicts.

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