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REVIEW
REVIEW
Management of Gastric Varices
Louis M. Wong Kee Song, M.D.
Gastric varices (GV) are present in approximately 20%
of patients with portal hypertension. GVs bleed less frequently than esophageal varices (EV), but bleeding is
more severe and mortality is higher. Risk factors for
gastric variceal bleeding (GVB) include variceal location
(particularly the fundus), size, overlying red signs, and
advanced liver disease.1
Classification of GV
The commonly used classification system introduced by
Sarin2 comprises four types of GV based on gastric location
and relationship with EV (Fig. 1). Gastroesophageal varices
(GOV) either are an extension of EV for 2 to 5 cm along the
lesser curve of the stomach (GOV1) or extend along the
greater curve into the fundus (GOV2). Isolated gastric varices
(IGV) are located either in the fundus (IGV1) or in other
parts of the stomach (IGV2). GOV1 account for 74% of all
GV, but the incidence of bleeding is highest with fundal varices (IGV1 and GOV2).1 Bleeding IGV1 require the exclusion
of isolated splenic vein thrombosis because therapy consists
of splenectomy.
Management of Acute Bleeding and
Prevention of Rebleeding
General Considerations
Similarly to patients with EV, patients with suspected GVB
should be managed in an intensive care unit with careful
blood volume resuscitation (target hemoglobin 8 g/dL),
administration of prophylactic antibiotics (intravenous ceftriaxone in high-risk patients), correction of significant clotting abnormalities, and endotracheal intubation in patients at
risk for aspiration. Despite the lack of efficacy data for GVB,
vasoactive agents (e.g., octreotide) are administered because
of their favorable safety profile and potential benefit. Variceal
tamponade with a large capacity balloon (e.g., a LintonNachlas tube) is used as bridge therapy in patients with massive or uncontrollable bleeding.
The optimal approach to GVB remains undefined because
of a lack of robust evidence-based data from large randomized trials and the inclusion of different types of GV among
studies. Several endoscopic, interventional radiologic, and
surgical treatment options are available. The selection of a
particular treatment modality is influenced in part by
patient characteristics, type of GV, available expertise,
technical/anatomical considerations, and therapy-specific
contraindications.
Endoscopic Intervention
Band Ligation and Sclerotherapy. The management of
GOV1 is similar to that of EV, and endoscopic band ligation
(EBL) is preferred to sclerotherapy because of a lower risk of
complications. However, EBL and sclerotherapy may be
ineffective therapies for fundal varices (GOV2 and IGV1)
because of high rebleeding rates and the potential for massive bleeding from large treatment-induced ulcers. EBL can
be used to control active fundal variceal bleeding if it is the
only available endoscopic option, but referral to a center for
performance of more definitive therapy (e.g., cyanoacrylate
injection) is recommended for prevention of rebleeding (secondary prophylaxis).
Cyanoacrylate Injection. Cyanoacrylate (glue) injection is
the recommended first-line therapy for GVB,3,4 with initial
control of bleeding in 90% to 100% of patients and
rebleeding rates <15% in recent series.5-7 Small controlled
trials also favor cyanoacrylate over sclerotherapy and EBL
with regard to initial hemostasis, rebleeding, and/or
Abbreviations: BRTO, balloon-occluded retrograde transvenous obliteration; EBL, endoscopic band ligation; EV, esophageal varices; GOV, gastroesophageal
varices; GRS, gastrorenal shunt; GV, gastric varices; GVB, gastric variceal bleeding; IGV, isolated gastric varices; NA, not applicable; TIPS, transjugular
intrahepatic portosystemic shunt.
From the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
Potential conflict of interest: Nothing to report.
View this article online at wileyonlinelibrary.com
C 2012 by the American Association for the Study of Liver Diseases
V
doi: 10.1002/cld.94
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Clinical Liver Disease, Vol. 1, No. 5, November 2012
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Management of Gastric Varices
R E V I E W
Wong Kee Song
TABLE 1: Cyanoacrylates Used for Gastric Variceal Bleeding
Mixed with Lipiodol
Cyanoacrylate/Lipiodol ratio
Injected volume per
puncture site
Maximum volume injected
per treatment session
N-Butyl-2
Cyanoacrylate
Octyl-2
Cyanoacrylate
Yes > No
1:1
1-2 mL
No
NA
2-4 mL
5 mL
10 mL
A dedicated 21-gauge injection catheter is recommended. Distilled water
or normal saline is used both for catheter priming and flushing of the glue.
Abbreviation: NA, not applicable.
additional benefit with regard to prevention of rebleeding
and mortality.13
The incidence of cyanoacrylate-related complications is
low, which include bleeding from early glue cast extrusion,
sepsis, and distant glue embolism.14 The presence of intracardiac or intrapulmonary shunts (as assessed by contrast
echocardiogram) and a large GRS heighten the risk for systemic glue embolization.1 The embolic risk may be minimized with the introduction of novel techniques, such as
EUS-guided coil/glue injection and the combined approach
of endoscopic cyanoacrylate injection with angiographic balloon occlusion of the GRS (Fig. 3), although additional appraisal of these modalities is warranted.15,16
FIGURE 1. Classification of GV.
complication rates.8-11 Cyanoacrylate is not approved by
the US Food and Drug Administration for intravariceal
injection, but it is used off-label with increasing frequency
in the United States.
Cyanoacrylate injection requires careful patient selection
and attention to technique for an optimal outcome.
Dynamic computed tomography is recommended to
determine the presence of spontaneous large splenorenal
or gastrorenal shunts (GRS). These shunts are associated
with the risk for systemic glue embolism. A standardized
injection protocol enhances procedural safety and efficacy,6 although technical variations exist depending on
the type of cyanoacrylate used and local expertise (Table
1). Complete variceal obturation, including tributaries, is
attempted at the initial session, and repeat endoscopy is
performed in 4 weeks to confirm GV obliteration or
treat residual varices (Fig. 2). Following variceal obliteration, surveillance endoscopy is typically performed at 3to 6-month intervals to monitor for variceal recurrence. A
glue cast may remain visible for weeks to months after
injection. Beta-blocker therapy alone is inferior to cyanoacrylate injection for secondary prophylaxis of GVB,12 and
its use in conjunction with cyanoacrylate provides no
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Clinical Liver Disease, Vol. 1, No. 5, November 2012
Miscellaneous. The clinical experience regarding injection
of thrombin or fibrin sealants for GVB is limited, with
reported rates of 70% to 100% for initial hemostasis and
0% to 50% for rebleeding.5 Embolic complications have not
been described, but leakage of thrombin into the systemic
circulation via a GRS could potentially induce disseminated
intravascular coagulation or pulmonary embolism. Controlled studies on the efficacy and safety of these agents for
GVB are needed before they can be recommended for use.
The use of detachable stainless steel or nylon snares for ligation of GV has been described, although ligation-induced
ulcer leading to life-threatening hemorrhage remains a
concern.17
Radiologic Intervention
Transjugular Intrahepatic Portosystemic Shunt (TIPS). TIPS
is effective at controlling GVB in over 90% of cases,
with reported rebleeding rates of 15% to 40% within 1
year.5 In one randomized trial, TIPS was more effective than
cyanoacrylate injection for prevention of recurrent bleeding
(11% versus 38%), although survival was similar and incidence of encephalopathy was higher in the TIPS group
(26% versus 3%).18 GV may bleed at significantly lower portal pressures than EV, and TIPS may be less effective in this
subgroup of patients in whom the hepatic venous pressure
gradient is low and a large GRS is present.19 Because
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Management of Gastric Varices
Wong Kee Song
FIGURE 2. (A) Actively bleeding IGV1. (B) Intravariceal 2-octyl cyanoacrylate injection. (C) Bleeding controlled immediately after cyanoacrylate injection. (D) Obli-
terated IGV1 with small retained glue cast at 1-month follow-up.
FIGURE 3. (A) Large IGV1 with stigmata of recent bleeding (arrow). (B) Endoscopic injection of cyanoacrylate-Lipiodol mixture into the varices. (C) Angiographic
balloon occlusion of GRS (arrowhead) during endoscopic injection (arrow) to minimize systemic glue embolization via the GRS. (D) Complete variceal eradication
(arrow) at 1-month follow-up.
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An Official Learning Resource of AASLD
Management of Gastric Varices
R E V I E W
Wong Kee Song
FIGURE 4. Suggested algorithm for management of acute GVB.
cyanoacrylate may be more cost-effective than TIPS,20,21 the
latter is generally used as rescue therapy after failed endoscopic intervention for acute GVB. Following the acute episode, either cyanoacrylate or TIPS can be recommended for
prevention of recurrent bleeding from fundal varices.
Balloon-Occluded Retrograde Transvenous Obliteration
(BRTO). BRTO is possible only in the presence of a GRS,
which is present in up to 85% of patients with GV.1 The
technique involves instillation of sclerosant22 or foam23 into
the GV via a balloon-occluding catheter placed through the
GRS. BRTO is used primarily in Japan for prevention of initial bleed and secondary prophylaxis of GVB, whereas its
use in the United States and Europe is sporadic. Uncontrolled data show excellent initial control of bleeding
(>90%), low rebleeding rates (0%-9%), and high variceal
eradication rates (75%-100%).5 Potential adverse effects
include fever, ascites, pleural effusions, and the development of EV in up to two-thirds of patients. Partial splenic
embolization preceding BRTO resulted in a significantly
reduced incidence of EV compared with BRTO alone (9%
versus 45%) by reducing blood inflow into the portal
vein.24 Where available, BRTO can be considered in
patients with GVB who have failed endoscopic therapy and
are poor candidates for TIPS.
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Clinical Liver Disease, Vol. 1, No. 5, November 2012
Surgical Intervention
Surgical intervention is considered a last resort when endoscopic and interventional radiologic therapies fail to control GVB in patients with good liver function (Child-Pugh
class A).
Prevention of Initial Bleeding
Beta-blockers may be considered for prevention of first
GVB (primary prophylaxis) even though their value is unproven in this setting. A recent, randomized, three-arm trial
favored cyanoacrylate injection over no therapy (for prevention of bleeding and survival) and propranolol (for prevention of bleeding only), although these findings require validation due to statistical uncertainty accounting for multiple
comparisons in this study.25 Although BRTO is used in Asia
for primary prophylaxis of GV at risk for bleeding, it is not
standard practice in most Western countries, and randomized trials are needed before this approach can be
recommended.
Summary
The management of bleeding GOV1 is the same as bleeding esophageal varices. Endoscopic cyanoacrylate injection is
considered first-line therapy for management of acute fundal
variceal bleeding (GOV2 and IGV1). If cyanoacrylate is
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R E V I E W
unsuccessful or unavailable, TIPS is recommended. BRTO is
a potential alternative in patients who are poor candidates
for TIPS. Following the acute episode, either cyanoacrylate
or TIPS is recommended for prevention of recurrent bleeding
from fundal varices (Fig. 4). No formal recommendations
can be made with regard to specific therapies for prevention
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Management of Gastric Varices
Wong Kee Song
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CORRESPONDENCE:
Louis M. Wong Kee Song, M.D., Division of Gastroenterology and
Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
E-mail: [email protected]
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