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JAMA Surg. 2019 Jun 1;154(6):540-548. doi: 10.1001/jamasurg.2019.0407.

Management Options for Gastric Variceal Hemorrhage.

Author information

1
Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles.
2
Division of Liver and Pancreas Transplantation, Department of Surgery, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles.

Abstract

Importance:

Varices are one of the main clinical manifestations of cirrhosis and portal hypertension. Gastric varices are less common than esophageal varices but are often associated with poorer prognosis, mainly because of their higher propensity to bleed.

Observations:

Currently, treatments used to control and manage gastric variceal bleeding include β-blockers, endoscopic injection sclerotherapy, endoscopic variceal ligation, endoscopic variceal obturation, shunt surgery, transjugular intrahepatic portosystemic shunts, balloon-occluded retrograde transvenous obliteration (BRTO), and modified BRTO. In the past few decades, Western (United States and Europe) interventional radiologists have preferred transjugular intrahepatic portosystemic shunts that aim to decompress the liver and reduce portal pressure. Conversely, Eastern radiologists (Japan and South Korea) have preferred BRTO that directly targets the gastric varices. Over the past 20 years, BRTO has evolved and procedure-related risks have decreased. Owing to its safety and efficiency in treating gastric varices, BRTO is now starting to gain popularity among Western interventional radiologists. In this review, we present a comprehensive literature review of current and emerging management options, including BRTO and modified BRTO, for the treatment of gastric varices in the setting of cirrhosis and portal hypertension.

Conclusions and Relevance:

Balloon-occluded retrograde transvenous obliteration has emerged as a safe and effective alternative treatment option for gastric variceal hemorrhage. A proper training, evidence-based consensus and guideline, thorough preprocedural and postprocedural evaluation, and a multidisciplinary team approach with BRTO and modified BRTO are strongly recommended to ensure best patient care.

PMID:
30942880
DOI:
10.1001/jamasurg.2019.0407

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