Gastric varices

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Gastric varices

Classification and external resources

Isolated gastric varices of Sarin classification

IGV-1 seen on gastroscopy in a patient
withportal hypertension

ICD-10 I86.4

Gastric varices are dilated submucosal veins in the stomach,

which can be a life-threatening cause of upper gastrointestinal
hemorrhage. They are most commonly found in patients
with portal hypertension, or elevated pressure in the portal
vein system, which may be a complication of cirrhosis. Gastric
varices may also be found in patients with thrombosis of
the splenic vein, into which the short gastric veins which drain
the fundus of the stomach flow. The latter may be a complication
 of acute pancreatitis, pancreatic cancer, or other abdominal
tumours. Patients with bleeding gastric varices can present with
bloody vomiting (hematemesis), dark, tarry stools (melena), or
frank rectal bleeding. The bleeding may be brisk, and patients
may soon develop shock. Treatment of gastric varices can include
injection of the varices with cyanoacrylate glue, or a radiological
procedure to decrease the pressure in the portal vein,
termed transjugular intrahepatic portosystemic shunt or TIPS.
Treatment with intravenous octreotide is also useful to shunt
blood flow away from the stomach's circulation. More aggressive
treatment including splenectomy (or surgical removal of
the spleen) or liver transplantation may be required in some
cases.
Contents
 [hide]

 1 Clinical presentation
 2 Diagnosis and
classification
 3 Treatment
 4 See also

[edit]Clinical presentation
Gastric varices can present in two major ways. First, patients
with cirrhosis may be enrolled in screening gastroscopy programs
to detect esophageal varices. These evaluations may detect
gastric varices that are asymptomatic. When gastric varices are
symptomatic, however, they usually present acutely and
dramatically with upper GI hemorrhage. The symptoms can
include hematemesis, or vomiting blood; melena, passing black,
tarry stools; or passing maroon stools or frank blood in the stools.
Many patients with bleeding gastric varices present in shock due
to the profound loss of blood.
Secondly, patients with acute pancreatitis may present with
gastric varices as a complication of thrombosis of the splenic vein.
The splenic vein sits over the pancreas anatomically and
inflammation or cancers of the pancreas may result in thrombosis,
or clotting of the splenic vein. As the short gastric veins of
the fundus of the stomach drain into the splenic vein, thrombosis
of the splenic vein will result in increased pressure and
engorgement of the short veins, leading to varices in the fundus of
the stomach.
Laboratory testing usually shows anemia and
often thrombocytopenia (a low platelet count). If cirrhosis is
present, there may be coagulopathy manifested by a
prolonged INR; both of these may worsen the hemorrhage from
gastric varices.
In very rare cases, gastric varices are caused by splenic vein
occlusion as a result of the mass effect of slow-growing
pancreatic neuroendocrine tumors.
[edit]Diagnosis and classification

The Sarin classification of gastric varices identifies two types

of gastroesophageal varices, where esophageal varices are found
concurrently, and two types ofisolated gastric varices, found in the absence
of esophageal varices.
Antral varices, of Sarin classification IGV-2, an unusual class of gastric
varices.

Diagnosis of gastric varices is often made at the time of

upper endoscopy.
The Sarin classification of gastric varices identifies four different
anatomical types of gastric varices, which differ in terms of
treatment modalities.
[edit]Treatment
Initial treatment of bleeding from gastric varices focuses on
resuscitation, much as with esophageal varices. This includes
administration of fluids, blood products, and antibiotics.
The results from the only two randomized trials comparing band
ligation vs cyanocarylate suggests that endoscopic injection
of cyanoacrylate, known asgastric variceal obliteration or GVO
is superior to band ligation in preventing rebleeding rates.
Cyanoacrylate, a common component in 'super glue' is often
mixed 1:1 with lipiodol to prevent polymerization in the endoscopy
delivery optics, and to show on radiographic imaging. GVO is
usually performed is specialized therapeutic endoscopy centers.
Complications include sepsis, embolization of glue, and
obstruction from polymerization in the lumen of thestomach.
Other techniques for refractory bleeding include:

 Transjugular intrahepatic portosystemic shunts (TIPS)

 Balloon occluded retrograde transvenous obliteration
techniques (BORTO)
 Gastric variceal ligation, although this modality is falling out
of favour
 Intra-gastric balloon tamponade as a bridge to further
therapy
 a caveat is that a larger balloon is required to occupy
the fundus of the stomach where gastric varices commonly
occur
 Liver transplantation