Gastric Varices

Gastric varices are abnormal, enlarged veins in the stomach. They often happen because of advanced liver disease like cirrhosis. These veins are similar to those in the esophagus but are in the stomach. They can be very dangerous because they might burst and cause severe bleeding.

It’s important to know about gastric varices for both patients and doctors. Recognizing the signs and risks early can help prevent serious problems. In this article, we’ll dive into what gastric varices are and how they’re treated.

What are Gastric Varices?

Gastric varices are abnormal, dilated blood vessels in the stomach. They happen because of portal hypertension. This is when blood flow through the liver is blocked, causing high pressure in stomach and esophagus veins.

Definition and Anatomy

Gastric varices are dilated veins in the stomach’s lining. They form due to high pressure in the portal venous system. These varices are less common than esophageal varices but harder to treat.

The stomach’s varices are located in different areas. They can be found in the fundus, body, or antrum. Each location has its own challenges and treatment options.

Types of Gastric Varices

Gastric varices are classified by their location and relation to esophageal varices:

• Gastroesophageal Varices (GOV): Extend from the esophagus into the stomach
  • GOV-1: Esophageal varices extending along the lesser curvature
  • GOV-2: Esophageal varices extending along the fundus
• Isolated Gastric Varices (IGV): Occur independently in the stomach without esophageal involvement
  • IGV-1: Located in the fundus
  • IGV-2: Located in the body, antrum, or pylorus

Knowing the types and locations of gastric varices is key. It helps doctors choose the right treatment. Each type needs a specific approach based on its unique features and risks.

Causes and Risk Factors

Several conditions and risk factors can lead to gastric varices. Portal hypertension and liver cirrhosis are the main culprits. They often work together to cause these enlarged veins in the stomach.

Portal Hypertension

Portal hypertension is a big risk for gastric varices. It happens when the blood pressure in the portal vein gets too high. This high pressure forces blood into smaller veins, making them swell and become varices.

The main reasons for portal hypertension include:

Liver Cirrhosis

Liver cirrhosis is another big risk for gastric varices. When the liver gets scarred, it can’t handle blood flow well. This leads to portal hypertension. Common causes of liver cirrhosis include:

• Chronic alcohol abuse
• Viral hepatitis B and C
• Non-alcoholic fatty liver disease

Other Contributing Factors

Other factors can also raise the risk of gastric varices. These include:

Splenic vein thrombosis: A blood clot in the splenic vein can cause localized portal hypertension and lead to isolated gastric varices.Gastrointestinal bleeding: A history of gastrointestinal bleeding, like from esophageal varices, may increase the chance of gastric varice formation.

By knowing these risk factors, doctors can spot patients at higher risk. They can then take steps to screen and prevent gastric varices.

Symptoms and Complications

Gastric varices often show no symptoms until serious complications happen. The biggest risk is gastrointestinal bleeding. This can cause severe anemia and even hemorrhagic shock.

People with bleeding gastric varices might feel:

The bleeding can be slow or sudden. Severe blood loss can lead to hypovolemic shock. Signs include low blood pressure, rapid pulse, and cold skin. Without quick treatment, it can be deadly.

After bleeding, patients might face iron-deficiency anemia. They may need blood transfusions and iron supplements. Also, there’s a high chance of bleeding again, so they need close monitoring and long-term care.

Diagnosis of Gastric Varices

It’s important to accurately diagnose gastric varices to choose the right treatment. Doctors use physical exams, endoscopy, and imaging to check for varices. They look at how severe they are.

Physical Examination

Doctors check for signs of high blood pressure in the portal vein during a physical exam. They look for an enlarged spleen or fluid in the belly. They also check for liver disease signs like jaundice and spider angiomas. But, more tests are needed to confirm gastric varices.

Endoscopic Evaluation

Endoscopy is the best way to find gastric varices. A thin tube with a camera is used to see inside the stomach. Doctors can see the varices and check if they might bleed. They use the Sarin classification to describe the varices based on what they see.

Imaging Techniques

Imaging is also key in diagnosing gastric varices. Ultrasound can spot signs of high blood pressure in the portal vein. Doppler ultrasound checks blood flow in the portal vein. CT scans and MRI give detailed pictures of the liver and spleen, helping doctors understand the varices better.

Treatment Options for Gastric Varices

Gastric varices need quick and effective treatment to avoid serious problems. The right treatment depends on the varices’ size, location, and the liver disease’s severity. Options include endoscopic therapy, TIPS, surgery, and medicine.

Endoscopic Treatments

Endoscopic therapy is often the first choice for treating gastric varices. There are two main methods: sclerotherapy and band ligation. Sclerotherapy uses a special agent to close the varices. Band ligation uses bands to cut off blood supply, causing the varices to shrink and disappear.

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

TIPS is a less invasive procedure that lowers portal pressure. It’s used when endoscopic therapy fails or when pressure is very high. While effective, TIPS can lead to complications like brain problems and shunt failure.

Surgical Interventions

Surgery is sometimes needed for gastric varices. Surgical options include removing the spleen, ligation of blood vessels, and shunt surgery. Surgery is usually a last resort for those who don’t respond to other treatments.

Pharmacological Management

Medicine helps manage gastric varices. Beta-blockers like propranolol and nadolol lower portal pressure. Vasoactive drugs, such as terlipressin and octreotide, help control bleeding. These medicines are used with endoscopic therapy or as a temporary solution.

Endoscopic Treatment Modalities

Endoscopic therapy is key in treating gastric varices. Several methods are effective in stopping bleeding and preventing it from coming back. The right treatment depends on the varix’s location, size, the patient’s health, and the doctor’s skills.

Sclerotherapy uses a special agent to close off the varix. This method can stop bleeding but might cause ulcers, holes in the stomach, or other serious issues.

Band ligation is another method, often used for esophageal varices. It involves placing bands around the varix to cut off blood flow. This method is safer than sclerotherapy and can effectively stop bleeding and close the varix.

Cyanoacrylate glue injection is a newer, promising treatment. It works by forming a solid plug in the varix. This method is very effective in stopping bleeding and closing the varix. But, it must be done carefully to avoid serious side effects.

Studies have shown how well these treatments work. Here’s a comparison of their success rates:

Choosing the right treatment depends on the patient and the doctor’s expertise. It’s important to keep an eye on how the treatment is working and watch for any problems. If the treatment doesn’t work or if bleeding comes back, other options like TIPS or surgery might be needed.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Procedure

The TIPS procedure is a minimally invasive treatment for patients with gastric varices due to portal hypertension. It creates a pathway in the liver to redirect blood flow. This reduces pressure in the portal venous system.

Indications and Contraindications

TIPS is for patients with gastric varices who haven’t responded to endoscopic treatments. It’s also for those at high risk for bleeding. But, it’s not for everyone.

Procedure Overview

An interventional radiologist accesses the hepatic vein through the jugular vein in the neck. Under fluoroscopic guidance, a stent is placed. This creates a shunt between the portal vein and the hepatic vein.

This allows blood to bypass the liver. It reduces portal pressure and the risk of bleeding from gastric varices.

Success Rates and Complications

TIPS has high success rates in controlling bleeding from gastric varices. Up to 90% of cases see immediate hemostasis. But, like any invasive procedure, there are risks.

• Hepatic encephalopathy
• Stent thrombosis or stenosis
• Bleeding at the access site
• Infection
• Liver failure

Despite these risks, TIPS is an effective treatment for select patients. It’s for those with gastric varices secondary to portal hypertension. These patients have failed or are not candidates for endoscopic therapies.

Surgical Options for Gastric Varices

When endoscopic treatments and TIPS don’t work, surgery might be needed. These surgeries aim to lower portal pressure and stop bleeding from varices. The splenorenal shunt and devascularization procedures are two common surgeries for this.

Splenorenal Shunt

The splenorenal shunt redirects blood flow from the splenic vein to the left renal vein. This method helps reduce pressure on the gastric varices. It creates a new blood flow path, which can stop bleeding and improve patient health.

This surgery is often done laparoscopically. It has shown good results in some patients with gastric varices.

Devascularization Procedures

Devascularization procedures cut off the blood supply to the gastric varices. This reduces the chance of bleeding. These surgeries can be open or laparoscopic, depending on the patient and surgeon.

While devascularization can control bleeding well, it might lead to more recurrence than shunt procedures.