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Clin Gastroenterol Hepatol. 2014 Jun;12(6):919-28.e1; quiz e51-2. doi: 10.1016/j.cgh.2013.07.015. Epub 2013 Jul 27.

Management of gastric varices.

Author information

1
Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain. Electronic address: jcgarcia@clinic.ub.es.
2
Diagnostic Imaging Center, Hospital Clinic, Barcelona, Spain.
3
GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clínic, University of Barcelona, IDIBAPS, CIBEREHD, Barcelona, Spain.
4
ICU, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.

Abstract

According to their location, gastric varices (GV) are classified as gastroesophageal varices and isolated gastric varices. This review will mainly focus on those GV located in the fundus of the stomach (isolated gastric varices 1 and gastroesophageal varices 2). The 1-year risk of GV bleeding has been reported to be around 10%-16%. Size of GV, presence of red signs, and the degree of liver dysfunction are independent predictors of bleeding. Limited data suggest that tissue adhesives, mainly cyanoacrylate (CA), may be effective and better than propranolol in preventing bleeding from GV. General management of acute GV bleeding must be similar to that of esophageal variceal bleeding, including prophylactic antibiotics, a careful replacement of volemia, and early administration of vasoactive drugs. Small sample-sized randomized controlled trials have shown that tissue adhesives are the therapy of choice for acute GV bleeding. In treatment failures, transjugular intrahepatic portosystemic shunt (TIPS) is considered the treatment of choice. After initial hemostasis, repeated sessions with CA injections along with nonselective beta-blockers are recommended as secondary prophylaxis; whether CA is superior to TIPS in this scenario is not completely clear. Balloon-occluded retrograde transvenous obliteration (BRTO) has been introduced as a new method to treat GV. BRTO is also effective and has the potential benefit of increasing portal hepatic blood flow and therefore may be an alternative for patients who may not tolerate TIPS. However, BRTO obliterates spontaneous portosystemic shunts, potentially aggravating portal hypertension and its related complications. The role of BRTO in the management of acute GV bleeding is promising but merits further evaluation.

KEYWORDS:

Balloon-occluded Retrograde Transvenous Obliteration (BRTO); Cirrhosis; Cyanoacrylate; Gastric Varices; Portal Hypertension; Transjugular Intrahepatic Portosystemic Shunt (TIPS); Variceal Bleeding

PMID:
23899955
DOI:
10.1016/j.cgh.2013.07.015
[Indexed for MEDLINE]

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