Varices gastric

Active bleeding. Acutely bleeding varices can be treated by injection sclerotherapy, by tamponade and by infusion systemically of vasopressin analogues or octreotide (which reduce variceal pressure). Results of controlled trials generally reflect efficacy in oesophageal rather than gastric variceal disease, which form a minority of cases, and can be more difficult to manage. 

Tripathi D, Eerguson JW, Therapondos G, Plevris JN, Hayes PC. Review article recent advances in the management of bleeding gastric varices. Aliment Pharmacol Ther 2006 24 1-18. 

High blood pressure in the portal veins (due to scarring), causing dilated, twisted veins to form at the lower end of the oesophagus (oesophageal varices), in the stomach (gastric varices) or... 

Endoscopy shows whether or not oesophageal or gastric varices are present, and hence whether collateral vessels have formed, affecting blood flow through the liver. 

Up to 50% of patients with portal hypertension bleed from oesophageal or gastric varices and half die from complications of their first bleed. Hypovolaemia must be corrected with plasma expanders and blood transfusion. Sepsis is common the incidence rises from 20% at 48 hours to over 60% at 7 days and antimicrobial prophylaxis should be given with ciprofloxacin (Ig/day). Some 70% will stop bleeding spontaneously but over half rebleed within 10 days. 

Sarin, S.K., Lahoti, D., Saxena, S.P., Murthy, N.S., Makwana, U.K. Prevalence, classification and natural history of gastric varices a longterm follow-up study in 568 portal hypertension patients. Hepatology 1992 16 1343-1349... 

In some cases, it may be helpful to use CT with gastric varices (183, 224) or MRI with oesophageal varices (140), portal biliopathy (78) and bleeding of gall-bladder varices. (79)... 

Fig. 19.12 Flow diagram therapeutic spectrum for acute upper gastrointestinal bleeding, including bleeding oesophageal and gastric varices...

Barange, K., Peron, XM., Imani, K., Otal, R, Payen, XL., Rousseau, H., Pascal, J.R, Joffre, F., Vinel, XR Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices. Hepatology 1999 30 1139-1143... 

Datta, D., Vlavianos, R, Alisa, A., Westaby, D. Use of fibrin glue (Beriplast) in the management of bleeding gastric varices. Endoscopy 2003 35 675-678... 

Dhiman, R.K., Chawla, Y., Taneja, S., Biswas, R., Sharma, T.R., Dila-wari, XB. Endoscopic sclerotherapy of gastric variceal bleeding with N-butyl-2-cyanoacrylate. J. Gastroenterol. Hepatol. 2002 35 222-227... 

Sato, T., Yamazaki, K., Toyota, J., Karino, Y., Ohmnra, T., Snga, T. Color Doppler findings of gastric varices compared with findings on computed tomography. J. Gastroenterol. 2002 37 604—610... 

Thomas, RG., D Cruz, A.X Distal splenorenal shunting for bleeding gastric varices. Brit. X Surg. 1994 81 241-244... 

Patients with portal hypertension will develop collateral pathways over time. Esophageal varices are very common, but gastric varices may also be observed (Schlesinger and Parker 2003 Itha and Yachha 2006). 

Balloon-occluded Retrograde Transvenous Obliteration of Gastric Varices in Portal Hypertension... 

The major aims of interventional procedures for portal hypertension are prophylactic and emergent treatment of variceal bleeding, control of hepatic encephalopathy, and treatment of refractory ascites. Hypersplenism associated with hematological disorder is an additional clinical problem in patients with portal hypertension. At present, the main primary embolotherapies available for portal hypertension are balloon-occluded retrograde transvenous obliteration (BRTO) and partial splenic embolization (PSE). In Japan, BRTO has recently been applied for gastric varices instead of either endoscopic treatment or transhepatic intrahepatic portosystemic shunt (TIPS) procedure, and numerous studies have reported that this method has an excellent success rate. Its efficacy for control of hepatic encephalopathy has also been demonstrated. 

Recently, BRTO as an alternative has been widely applied for the treatment of gastric varices in Japan, and favorable results - i.e., a success rate of greater than 90% and recurrence rate of less than 10% - have been reported. BRTO can be performed in patients with poor hepatic function reserve or hemorrhagic disorders. And because it is less invasive than other procedures, BRTO is expected to get more acceptances for treatment of gastric varices in the future. 

Fig. 8.1. Diagram of anatomy of the gastric varices and collateral vessels. AdV, adrenal vein BaC, balloon catheter CV, coronary vein IpVy inferior phrenic vein IVCy inferior vena cava G-RSy gastro-renal shunt GVy gastric varices MC, microcatheter PcVy pericardiacophrenic vein PGVy posterior gastric vein PVy portal vein RVy renal vein SGV, short gastric vein Spy spleen SpVy splenic vein...

BRTO has been proven clinically effective and safe in treatment of isolated gastric varices secondary to portal hypertension. More randomized perspective studies may be necessary to evaluate its usefulness in a worldwide scope and its relationship with other alternatives such as endoscopic therapies and TIPS... 

Barange K, Peron JM et al. (1999) Transjugular intrahe-patic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices. Hepatology 30 1139-1143... 

Fukuda T, Hirota S et al. (2001) Long-term results of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy. J Vase Interv Radiol 12 327-336... 

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