Lecture: managing gastric varices

Today’s lecture was about management of gastric varices.  They bleed about half as frequently as esophageal varices.  The most concerning ones have several features.  First is location: gastric varices bleed more frequently if they are isolated along the greater curvature (IGV 1) or if they are contiguous with esophageal varices and run along the greater curvature (GOV 2).  Furthermore, there are three risk factors for bleeding: size of gastric varix > 2cm, MELD > 17, or presence of portal hypertensive gastropathy.

It is clear that glue injection is superior to banding ligation as well as alcohol injection.  With respect to glue injection as primary prophylaxis, there is not great data, though if some of the above RF are present, the procedure is associated with good outcomes.

For secondary prophylaxis, glue injection was compared to beta-blockade and no therapy.  It is clear that glue injection is superior to beta-blockade, and beta-blockade is superior to no therapy.  (The volume of glue injected was, on average, 3.7 cc).  Nevertheless, even with glue injection, rebleeding rates are still > 20%.  This is why you should also consider TIPS for gastric variceal bleeding.  If the patient has a low MELD score and is previously compensated (ie. Child class A), consideration should be given for TIPS instead of glue in the early bleeding period.  While TIPS is well-known to decompress the right-sided portal hypertension seen with esophageal varices, it is also helpful for the left-sided portal hypertension caused by cirrhosis.

A future strategy may include the B-RTO.  This is a relatively new procedure that accesses the portal system via the femoral vein, and via catheter, injects glue into the gastric varices.  Early reports are promising.

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