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Gastric fundal varices: new aspects of nonsurgical treatment in Japan

Nature Clinical Practice Gastroenterology & Hepatology volume 3, pages 4–5 (2006)Cite this article

Among the complications of portal hypertension, gastric variceal bleeding is more serious than bleeding from esophageal varices, and still presents a therapeutic challenge. When treating gastric varices, clinicians should pay attention to the fact that the behavior of these lesions varies according to their location. Gastric varices have been divided into gastroesophageal varices (GEV) and isolated gastric varices (IGV). GEV type 1 (GEV1) extend along the lesser curve and GEV type 2 (GEV2) along the greater curve. IGV type 1 (IGV1) are isolated fundal varices and IGV type 2 (IGV2) are isolated ectopic gastric varices. IGV1 are confined to the fundus (or the cardia and fundus) and are not associated with esophageal varices. IGV1 and GEV2 bleed more often (78% and 54%, respectively) and more heavily than GEV1.1 Chikamori and colleagues reported that the portoazygos venous system contributes to the formation of esophageal and cardiac varices, whereas the portophrenic system is involved in the formation of IGV1.2 Watanabe et al. studied a series of patients with IGV1 and concluded that superior mesenteric venous flow was diverted away from the liver and directed into the gastrorenal shunt via the feeding vein for the varices. The portal pressure gradient (PPG) of large IGV1 is therefore quite low, whereas collateral flow into the varices is abundant. In addition, these patients are likely to develop hepatic encephalopathy.3

It has been reported that esophageal varices rarely bleed when the PPG is <12 mmHg and transjugular intrahepatic portosystemic shunting (TIPS) is considered to be a second-line treatment for patients with GEV that are unresponsive to pharmacologic and endoscopic treatment. Tripathi et al. reported that bleeding from IGV1 can occur even when the PPG is <12 mmHg and that TIPS only improved the mortality rate in patients with bleeding at a PPG ≥12 mmHg.4 Furthermore, Rinellar and colleagues concluded that portal decompression alone could not prevent recurrent bleeding via a splenogastrorenal shunt.5 Accordingly, decompressive procedures such as TIPS do not seem to provide much benefit for patients with IGV1 who have a major shunt and low PPG. Obliteration of such IGV1 by a safer procedure could therefore be justifiable.

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Authors and Affiliations

  1. Department of Gastroenterology, Racto Clinic,

    Akio Matsumoto & Kengo Takimoto

  2. Department of Gastroenterology, Takeda General Hospital, Kyoto, Japan

    Akio Matsumoto & Kengo Takimoto

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  1. Akio Matsumoto
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  2. Kengo Takimoto
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Correspondence to Akio Matsumoto.

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Matsumoto, A., Takimoto, K. Gastric fundal varices: new aspects of nonsurgical treatment in Japan. Nat Rev Gastroenterol Hepatol 3, 4–5 (2006). https://doi.org/10.1038/ncpgasthep0364

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