Gastric varices: Kurdistan Board GEH Journal club.

2. Introduction:
Prevalence of GV cirrhosis is 17%.
GV are classified as:
GOV
Isolated gastric varices (IGV).
GOV are divided as:
GOV1: extend below the GEJ along the lesser curve
GOV2 : extend beyond the GEJ into the fundus.

3. Introduction:
IGV includes:
IGV1:located in the fundus (fundal varices)
IGV2: ectopic varices located anywhere in the stomach
GOV1 represent almost 75%.
Cardiofundal varices : GOV2 21%., IGV1 <2%.
IGV2 4% of all GV.
GOV1 are a continuation of EV& share the same vascular
anatomy& response to treatment.
The management of IGV2 is similar to that of IGV1.

6. Primary prophylaxis:
Cirrhosis & cardiofundal varices (IGV1 &GOV2), the
incidence of bleeding 16%, 36%,44% at 1, 3& 5 years,
respectively.
Risk of bleeding:
Size of varices
Presence of red signs
Degree of liver dysfunction
(From 4% in Child class A with small varices without red
signs-65% in Child class C with large varices with red
signs).

7. Larger studies are needed before a formal
recommendation in regard to the need & type of primary
prophylaxis for GV can be made.
Until then, our recommendation is not to use primary
prophylaxis in GV or alternatively NSBB.
Primary prophylaxis:

8. Managemt of acute variceal bleeding:
General consensus is that the initial management is similar
to that of EV bleeding:
Prophylactic antibiotics.
Careful volume replacement with a restrictive transfusion
policy.
Early use of vasoactives(terlipressin,SST, or analogues).
IGV1 varices, which often appear as a consequence of
large spontaneous splenorenal shunts, may bleed with
portal pressure gradients lower than those needed for EV.
So more powerful vasoconstrictors are needed not only to
decrease portal pressure but also to markedly reduce
portal & collateral blood flow to control acute cardiofundal
variceal bleeding.

9. Managemt of acute variceal bleeding:
40% with bleeding IGV1 only receiving vasoactive drugs
require rescue therapy, mainly TIPS, to achieve 5-day
control of bleeding, so we currently do not recommend
using vasoactive drugs alone but always with concomitant
endoscopic therapy.
Most uncontrolled & controlled series for the control of
bleeding have shown that tissue adhesives are equally or
more effective than EBL or EIS.
GOV1 varices are usually treated as EV with EBL, although
some investigators also recommend tissue adhesives.
Overall, experts agree that endoscopic therapy with tissue
adhesives, mainly CA, is the therapy of choice for acute
bleeding from IGV1&GOV2.

10. Managemt of acute variceal bleeding:
EBL seems to have some benefit in small GOV2 varices if
CA is not available.
The standard protocol uses CA& lipiodol in 1:1 ratio,
injecting with no >1 mL at the varix each.
In most cases, CA is usually extruded into the stomach
lumen within 1– 3 months after injection.
The most rational approach is to combine drug therapy
plus endoscopic treatment (preferably tissue adhesives) in
patients with acute GV bleeding.

11. Managemt of acute variceal bleeding:
Complications of CA injection:
Rebleeding due to extrusion of the glue cast (4.4%)
Sepsis (1.3%)
Distant emboli (pulmonary, cerebral, splenic; 0.7%-2-3%),
Gastric ulcer (0.1%)
Major gastric variceal bleeding (0.1%),
Mesenteric hematoma associated with hemoperitoneum &
bacterial peritonitis (0.1%).
The complication-related mortality was 0.5%.

12. Managemt of acute variceal bleeding:
In massive bleeding with hemodynamic instability, balloon
tamponade (Linton– Nachlas better than SB) may achieve
hemostasis in up to 80% &can be used as a temporary “
bridge” (for a maximum of 24 hours) until definitive
treatment can be instituted. although more than 50% of the
cases rebleed after balloon deflation.
TIPS is of choice in bleeding GOV2 or IGV1 after failure to
control initial bleeding or rebleeding with combination trt.
Contrary to EV bleeding, a second-attempt endoscopic therapy
is usually not considered.
Embolization of collaterals feeding GV increase theeffi cacy of
the TIPS procedure if the portal pressure gradient after TIPS is
not reduced below 12.

13. Managemt of acute variceal bleeding:
TIPS is highly effective in achieving initial hemostasis in
GOV1&GOV2 varices.
Early (72 hs from bleeding) TIPS can be considered as a
first-line treatment in patients with GV/EV bleeding at high
risk of treatment failure (Child class C <14 points or Child
class B with active bleeding) because it reduces the risk of
treatment failure and improves survival in comparison with
conventional treatment with drugs + endoscopic therapy.

14. Secondary prophylaxis:
Rebleeding after an acute GV bleeding episode treated
with tissue adhesives (mainly CA) 7– 65%, mostly < 15%.
So after initial hemostasis with tissue adhesives, repeated
sessions every 2-4-week( 2-4 injs 1-2 ml/session), until
endoscopic obliteration is achieved.
CA better than EBL or other sclerotherapies.
EUS– guided therapy for fundal GV (IGV1&GOV2) with CA
&fibered coils may improve the efficacy of the technique.
More needed for TIPS in the secondary prophylaxis of GV
bleeding ? applied or reserved as a rescue therapy after
failure of more conservative approaches.

15. Secondary prophylaxis:
Surgery fallen out of favor for patients with portal
hypertension because of the wide availability of less
invasive endoscopic &interventional radiology.
In selected cases, patients with GV & segmental/left-sided
portal hypertension due to isolated splenic vein
thrombosis, may be candidates for splenectomy or splenic
embolization as a means of definitive therapy.

16. Other endoscopic therapies:
Sclerotherapy abandoned because of high rebleeding
rates (50%– 90%).
Variceal band ligation may be used for those patients with
GOV1&in some cases of small GOV2, generally every 2
weeks until apparent endoscopic obliteration,but cannot be
used in large GOV2 or IGV1.
Detachable loop snares to treat large GV (> 2 cm) along
with propranolol have resulted in low rebleeding rates,but
not rcommended.
Human throbmin inj 1500- 2000 U: safe, effective In acute
GV bleeding, with success 70– 100%; rebleeding 7%– 50%,
so repeated 2– 3 weeks until eradication,but Can not be
routinely recommended.

17. Balloon-occluded Retrograde Transvenous Obliteration
(BRTO):
There is a lack of good quality data to routinely
recommend BRTO in the management of GV.
BRTO could be considered in patients with GV bleeding &
large gastrorenal shunts in whom TIPS may be
contraindicated (refractory hepatic encephalopathy or
elderly patients).
BRTO is effective & has the potential benefit of increasing
portal hepatic blood flow so may be an alternative for
patients who may not tolerate TIPS.
BRTO obliterates spontaneous portosystemic shunts,
potentially aggravating portal hypertension &related
complications.

20. Summary:
No specific recommendations for PP of GV but NSBB given
if they have concomitant esophageal varices.
After initial resuscitation and implementation of
vasoconstrictors & antibiotics, endoscopic therapy with
CA should be the first line of therapy if available.
After the acute episode, patients should receive NSBB with
repeated sessions of CA injection if available.
TIPS is very effective in controlling active GV bleeding &for
secondary prophylaxis,but it carries a risk of HE.
TIPS is the best treatment strategy for patients who fail
endoscopic therapy.

22. Question 1:
What is the estimated prevalence of gastric varices in
patients with cirrhosis?
a. 10%
b. 32%
c. 17%
d. 54%
e. 70%

23. Question 2:
According to Sarin’s classification, GOV1 represent what
percent of gastric varices?
a. 75%
b. 50%
c. 21%
d. 4%
e. 2%

24. Question 3:
What is the best endoscopic approach for actively bleeding
gastric varices–GOV2?
a. Endoscopic sclerotherapy
b. Endoscopic band ligation
c. Cyanoacrylate injection
d. Thrombin injection
e. Detachable loop snares

25. Question 4:
Which of the following is the best initial strategy for
secondary prophylaxis after an episode of acute bleeding
from gastric varices–GOV2?
a. Beta-blockers plus endoscopic band ligation
b. Beta-blockers plus cyanoacrylate injection
c. Beta-blockers
d. TIPS
e. BRTO