title: Management of gastric varices.
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.
authors.affiliation: 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.
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Garcia-Pagán
authors.affiliation: Diagnostic Imaging Center, Hospital Clinic, Barcelona, Spain.
authors.forename: Marta
authors.initials: M
authors.lastname: Barrufet
authors.affiliation: GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clínic, University of Barcelona, IDIBAPS, CIBEREHD, Barcelona, Spain.
authors.forename: Andres
authors.initials: A
authors.lastname: Cardenas
authors.affiliation: ICU, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.
authors.forename: Angels
authors.initials: A
authors.lastname: Escorsell
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D021721:Balloon Occlusion / Q000379:methods*; D002317:Cardiovascular Agents / Q000627:therapeutic use; D003487:Cyanoacrylates / Q000627:therapeutic use; D004932:Esophageal and Gastric Varices / Q000188:drug therapy* / Q000601:surgery*; D006471:Gastrointestinal Hemorrhage / Q000517:prevention & control*; D006801:Humans; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000379:methods*; D011433:Propranolol / Q000627:therapeutic use; D014014:Tissue Adhesives / Q000627:therapeutic use*
chemical_list: D000900:Anti-Bacterial Agents; D002317:Cardiovascular Agents; D003487:Cyanoacrylates; D014014:Tissue Adhesives; D011433:Propranolol
keywords: Balloon-occluded Retrograde Transvenous Obliteration (BRTO); Cirrhosis; Cyanoacrylate; Gastric Varices; Portal Hypertension; Transjugular Intrahepatic Portosystemic Shunt (TIPS); Variceal Bleeding