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.

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.

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).

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:

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.

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.

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.

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%.

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.

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.

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.

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.

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.

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.

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.

Question 1:

What is the estimated prevalence of gastric varices in patients with cirrhosis?

a. 10%

b. 32%

c. 17%

d. 54%

e. 70%

Question 2:

According to Sarin’s classification, GOV1 represent what percent of gastric varices?

a. 75%

b. 50%

c. 21%

d. 4%

e. 2%

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

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