Gastric varices

Gastric varices are dilated submucosal veins in the stomach, which can be a life-threatening condition due to the risk of bleeding. They are most commonly a consequence of portal hypertension, often secondary to cirrhosis. Gastric varices are less prevalent than esophageal varices, yet they can bleed more severely and are more challenging to treat.

Etiology

Gastric varices develop when there is an obstruction in the portal vein or its branches, leading to increased pressure in the portal venous system. This condition, known as portal hypertension, forces blood to find alternative pathways to return to the heart, leading to the formation of varices in the stomach and esophagus. The most common cause of portal hypertension is liver cirrhosis, a result of chronic liver disease.

Classification

Gastric varices are classified based on their location and the presence of esophageal varices. The most widely used classification is by Sarin et al., which divides gastric varices into two main types:

• Gastroesophageal varices type 1 (GOV1): These extend along the lesser curvature of the stomach and are continuous with esophageal varices.
• Gastroesophageal varices type 2 (GOV2): These are found along the fundus of the stomach and may also be associated with esophageal varices.
• Isolated gastric varices (IGV): These are further divided into IGV1, located in the fundus, and IGV2, found in other parts of the stomach.

Symptoms

Many individuals with gastric varices do not exhibit symptoms until they bleed. Signs of bleeding can include:

• Vomiting blood (hematemesis)
• Black, tarry stools (melena)
• Lightheadedness
• Shock in severe cases

Diagnosis

Diagnosis of gastric varices is primarily made through endoscopy, which allows direct visualization of the varices. Other diagnostic tools include:

• Computed tomography (CT) scan: Can help in assessing the liver and spleen size and detecting signs of portal hypertension.
• Endoscopic ultrasound (EUS): Useful for evaluating the size and blood flow within the varices.

Treatment

The management of gastric varices focuses on preventing bleeding and treating active bleeding episodes. Treatment options include:

• Non-selective beta-blockers: Used to reduce portal hypertension and the risk of bleeding.
• Endoscopic treatment: Including endoscopic variceal ligation (EVL) and endoscopic sclerotherapy, though these are more challenging in gastric varices compared to esophageal varices.
• Balloon-occluded retrograde transvenous obliteration (BRTO): A procedure that involves the occlusion of the varices by injecting a sclerosing agent.
• Transjugular intrahepatic portosystemic shunt (TIPS): A procedure that creates a new pathway for blood flow within the liver, reducing portal pressure.

Prognosis

The prognosis for patients with gastric varices depends on the severity of the underlying liver disease and the success of bleeding control measures. Bleeding from gastric varices is associated with a high mortality rate, emphasizing the importance of early detection and treatment.

Prevention

Preventive measures for gastric varices are primarily aimed at managing liver disease and reducing portal hypertension. Regular monitoring and screening for varices in individuals with known risk factors are crucial for early intervention and prevention of complications.

‎