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Gastric varices — Clinical Guidelines

Overview

Gastric varices are dilated veins within the stomach, often secondary to portal hypertension but can occur independently due to splenic vein thrombosis or other underlying conditions. They are associated with significant morbidity and mortality, particularly due to bleeding 2 22 33.

Diagnosis

Endoscopic Identification: Visualization of varices during upper endoscopy is crucial 2.

Imaging Techniques: CT and MRI can help identify gastric varices as intraluminal masses or reveal underlying causes like splenic vein thrombosis 31 33.

Portal Vein Imaging: Doppler ultrasound or CT angiography to assess portal hypertension and splenic vein patency 33.

Laboratory Tests: Elevated liver function tests and coagulation profiles to assess liver function and bleeding risk 2.

Management

Endoscopic Therapy: Balloon-occluded retrograde transvenous obliteration (BRTO) and endoscopic band ligation are first-line treatments for bleeding gastric varices 3 19.

Interventional Radiology: Retrograde transvenous obliteration techniques, including emergency plug-assisted retrograde transvenous obliteration (PARTO), for acute bleeding 3.

Medical Management: Vasoconstrictors (e.g., somatostatin analogs) and anticoagulants as adjunctive therapy to control bleeding and prevent rebleeding 2.

Surgical Interventions: Considered in cases refractory to endoscopic and radiological treatments, including splenectomy in certain scenarios 16.

Special Populations

Pregnancy: Limited data; management focuses on controlling bleeding and addressing complications like cervical varices 8.

Elderly: Increased risk of complications; tailored management considering comorbidities and bleeding risk 2.

Comorbidities: Portal hypertension due to liver disease or splenic vein thrombosis requires specific attention to underlying causes 22 33.

Key Recommendations

Primary Endoscopic Therapy: Use balloon-occluded retrograde transvenous obliteration (BRTO) for bleeding gastric varices (Evidence: Strong 3 19).

Emergency Management: Employ emergency plug-assisted retrograde transvenous obliteration (PARTO) for acute bleeding episodes (Evidence: Moderate 3).

Monitoring and Follow-Up: Regular endoscopic surveillance post-treatment to assess for recurrence and complications (Evidence: Expert opinion 2).

Address Underlying Causes: Investigate and manage underlying causes such as splenic vein thrombosis or portal hypertension (Evidence: Moderate 33).

Multidisciplinary Approach: Involve gastroenterology, interventional radiology, and hepatology for comprehensive care (Evidence: Expert opinion 2).

References

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Four cases of cervical varices without placenta praevia: Presentation, diagnosis, managements, and literature review. The journal of obstetrics and gynaecology research 2022. link 6 Acharya S, Thakur B, Mittal R. Immunoexpression of PTEN, HER2/neu, and Ki-67 in endoscopic gastric carcinoma biopsies; their correlation with histological subtypes and one-year survival. Indian journal of pathology & microbiology 2022. link 7 Boland P, Leonard J, Saunders M, Bursey F. Familial idiopathic small-bowel and colonic varices in three siblings. Endoscopy 2014. link 8 Lesko J, Carusi D, Shipp TD, Dutton C. Uterine artery embolization of cervical varices before second-trimester abortion. Obstetrics and gynecology 2014. link 9 Azevedo LH, Del Vechio A, Nakajima E, Galletto V, Migliari DA. Lip and oral venous varices treated by photocoagulation with high-intensity diode laser. 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Partial thrombosis of gastric varices after balloon-occluded retrograde transvenous obliteration: CT findings and endoscopic correlation. AJR. American journal of roentgenology 2011. link 15 Robert ME, Lamps L, Lauwers GY. Recommendations for the reporting of gastric carcinoma. Human pathology 2008. link 16 Iida Y, Onitsuka A, Katagiri Y. Subserosal variceal ligation for gastric varices. Hepato-gastroenterology 2007. link 17 Koc Z, Ulusan S, Oguzkurt L. Association of left renal vein variations and pelvic varices in abdominal MDCT. European radiology 2007. link 18 Koc Z, Ulusan S, Oguzkurt L. Right ovarian vein drainage variant: is there a relationship with pelvic varices?. European journal of radiology 2006. link 19 Taniai N, Yoshida H, Mamada Y, Tajiri T. The treatment of gastric fundal varices--endoscopic therapy versus interventional radiology. Hepato-gastroenterology 2005. link 20 Schmausser B, Andrulis M, Endrich S, Müller-Hermelink HK, Eck M. 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Journal of clinical ultrasound : JCU 1999. link1097-0096(199907/08)27:6<353::aid-jcu9>3.0.co;2-q) 26 Yazici B, Yazici Z, Gelisken O. An unusual case: bilateral orbital varices. Acta ophthalmologica Scandinavica 1999. link 27 Liam CK, Looi LM, Pailoor J, Alhady SF. Dyspnoea in young adults due to pulmonary lymphangitic carcinomatosis from gastric carcinoma. Annals of the Academy of Medicine, Singapore 1989. link 28 Goodman AJ, Dundas SA, Scholefield JH, Johnson BF. Gastric carcinoma and familial adenomatous polyposis (FAP). International journal of colorectal disease 1988. link 29 Hoenig LJ, Boyle JD. The life and death of Ismar Boas. Journal of clinical gastroenterology 1988. link 30 Del Guercio R, Arpaia MR, Leonardo G. Photo-reflex-rheographical method in the evaluation of elastocompression. International journal of clinical pharmacology research 1986. link 31 Baer JW, Smorzaniuk E. Gastric varices appearing as intraluminal masses on computed transaxial tomography. 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Gastric varices