Gastric varices (GV) are distended veins caused by increased hydrostatic pressure in the portal system, with multiple etiologies. Bleeding may be acute or chronic. GV are often associated with liver disease and may occur together with esophageal bleeds. The former do not bleed as often as esophageal varices, and spontaneous cessation of bleeding is possible, with a risk of re-bleeding [1].

There are a number of classification systems used for GV. One such classification divides them into those caused by isolated splenic vein thrombosis (SVT), and those due to portal hypertension, the latter being the more frequently reported cause [2]. GV can occur through the short gastric veins in the case of SVT, and in this particular etiology, management is challenging as there tends to be multiple varices occurring simultaneously. Other classification systems include the Sarin and the Japanese vascular classification systems, which consider numerous factors such as the vasculature, location, and appearance of varices [3] [4].

The majority of individuals that have isolated GV are asymptomatic, and the diagnosis is made incidentally. Rupture of GV causes painless bleeding from the upper gastrointestinal (GI) tract. GV tend to bleed copiously, thus some patients may present in hypovolemic shock, and fatalities are more common compared to esophageal bleeds [2]. In cases with left-sided portal hypertension, additional signs such as ascites and abdominal pain may be noticed [5]. Splenomegaly may be found on clinical examination.

Other possible presentations are hematemesis which may consist of bright red blood or coffee grounds vomitus, melena, or hematochezia which can signify a massive upper GI bleed. Occult bleeds may only be detected through biochemical testing of stool.

• Hematemesis

  A 49-year-old woman with hepatitis C and peptic ulcer disease presented to the emergency department after an onset of sudden massive hematemesis. She had a history of alcohol abuse, but denied any recent excessive drinking. [ncbi.nlm.nih.gov]

  Center: 55 year-old man with alcoholic cirrhosis who presented with massive hematemesis (vomiting blood). Active pulsatile bleeding from a gastric fundic varix was seen at endoscopy. [endoatlas.com]

• Melena

  Two patients with liver cirrhosis and portal hypertension related to hepatitis infection were admitted to Shanghai Ruijin Hospital due to recurrent melena and hematemesis. [ncbi.nlm.nih.gov]

  Patients with bleeding gastric varices can present with bloody vomiting ( hematemesis ), dark, tarry stools ( melena ), or rectal bleeding. The bleeding may be brisk, and patients may soon develop shock. [en.wikipedia.org]

  Other possible presentations are hematemesis which may consist of bright red blood or coffee grounds vomitus, melena, or hematochezia which can signify a massive upper GI bleed. [symptoma.com]

• Gastropathy

  Gastric variceal hemorrhage, severe portal hypertensive gastropathy, splenic vein thrombosis. Blood transfusion, splenic artery embolization and balloon-occluded retrograde transvenous obliteration of gastric varices. [ncbi.nlm.nih.gov]

  There are studies which show that sclerotherapy can lead to worsening of portal hypertensive gastropathy. [ghrnet.org]

  Pulmonary embolism, cardiac arrhythmia, anaphylaxis, portal hypertensive gastropathy, worsening esophageal varices, duodenal varices, worsening ascites, and bacterial peritonitis have also been reported. [massgeneral.org]

  In addition, findings from retrospective case series have suggested that it helps in cases of: Acute variceal bleeding refractory to endoscopic therapy Gastropathy due to portal hypertension Bleeding gastric varices Refractory hepatic hydrothorax Hepatorenal [mdedge.com]

• Intestinal Perforation

  KEYWORDS: Endoscopy; Hemostasis; Intestinal Perforation; Ligation; Varix [ncbi.nlm.nih.gov]

In patients with gastric varices, it is important to investigate for the common underlying conditions. If varices are actively bleeding, the workup includes both diagnostic as well as therapeutic interventions, usually in the form of endoscopy. This is done after hypovolemia has been addressed with careful intravenous fluid therapy.

Laboratory investigations for liver disease, such as liver function tests and clotting studies, are usually conducted. Biopsy followed by histological analysis of liver tissue may also be carried out. Blood typing and crossmatching are also useful, as some people may require transfusion.

During the endoscopic evaluation, GV may be more adequately visualized by the insertion of a nasogastric tube for gastric lavage, endoscopic suction, or the use of prokinetic drugs to accelerate gastric emptying.

Radiological techniques are employed in the evaluation of the veins of the portal system. The modalities often used are:

• Endoscopy: This has a good detection rate, reported to be as high as 90% [6]. It is accurate in localizing the GV, and identifying non-variceal upper GI bleeding.
• Angiography.
• Ultrasonography: This can either be done via the trans-abdominal or endoscopic route and is instrumental in detecting splenic vein and pancreas pathologies. Endoscopic ultrasound is preferred, as it is more accurate [7].
• Computed tomography (CT) portography: This is carried out as a contrasted study, used in the evaluation of the portal system.
• Magnetic resonance imaging (MRI) [8].

We basically applied endoscopic glue embolization using cyanoacrylate monomer for treatment of acute bleeding. [ncbi.nlm.nih.gov]

EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years (with video) Gastrointestinal Endoscopy 2015.65. Khokhar OS et al. [sapd.es]

Treatment [ edit ] Initial treatment of bleeding from gastric varices focuses on resuscitation, much as with esophageal varices. This includes administration of fluids, blood products, and antibiotics. [en.wikipedia.org]

The underlying cause determines the clinical significance and prognosis of HPVG. [ncbi.nlm.nih.gov]

Outflow Type A - drained by a single large shunt Type B - drained by a single shunt + smaller collateral veins Type C - drained by both gastro-renal and gastro-caval shunts Type D - not continuous with a shunt (multiple smaller collaterals) Treatment and prognosis [radiopaedia.org]

Gastric varices (GV) are distended veins caused by increased hydrostatic pressure in the portal system, with multiple etiologies. Bleeding may be acute or chronic. [symptoma.com]

The etiologies were acute pancreatitis in one patient, chronic pancreatitis in seven patients, and pancreatic tumors in 13 patients. [ncbi.nlm.nih.gov]

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. [aapc.com]

There are multiple other terms used globally, and although there are reported differences in etiology, epidemiology, and hepatic pressures, these various presentations likely reflect the vast spectrum of the condition itself and not the distinct diseases [cureus.com]

This article reviews the pathophysiology, classification, and management of patients with gastric varices and outlines the importance of the nurse's role in the education and ongoing care for this patient group. [ncbi.nlm.nih.gov]

Unlike others on this topic, this text demonstrates how the endoscope incorporates pathophysiology, diagnostic, and treatment modalities into endoscopic practice. [books.google.com]

Eight of the 14 patients had adequate clinical and/or radiologic follow-up to suggest the pathophysiology of the varices. Seven had evidence of portal hypertension, and the remaining patient had evidence of splenic vein obstruction. [link.springer.com]

When compared with esophageal varices, GV differs in natural history, morphology, and pathophysiology. GV is rare occurring in about 33% of cases. [news-medical.net]

There was low quality evidence for the prevention of re-bleeding (RR 0.60; 95% CI 0.41 to 0.88). [ncbi.nlm.nih.gov]

Can also be used to prevent releeding. [1] BRTO is not suitable for gastric varices that lack a main draining vein, as they cannot be catheterized. [4] Prevention of rebleed (secondary prophylaxis) - Non selective β-blockers [1] These medications reduce [explainmedicine.com]

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am. J. Gastroenterol. 2007. de Franchis R. [sapd.es]

Cyanoacrylate, a common component in 'super glue' is often mixed 1:1 with lipiodol to prevent polymerization in the endoscopy delivery optics, and to show on radiographic imaging. [en.wikipedia.org]

1. Graham DY, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology. 1981;80(4):800-809.
2. Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology. 1992;16(6):1343–1349.
3. Caldwell SH, Hespenheide EE, Greenwald BD, Northup PG, Patrie JT. Enbucrilate for gastric varices: extended experience in 92 patients. Aliment Pharmacol Ther. 2007;26(1):49–59.
4. Arakawa M, Masuzaki T, Okuda K. Pathology of fundic varices of the stomach and rupture. J Gastroenterol Hepatol. 2002;17(10):1064–1069.
5. Köklü S, Yüksel O, Arhan M, et al. Report of 24 left-sided portal hypertension cases: a single-center prospective cohort study. Dig Dis Sci. 2005;50(5):976-982.
6. Mathur SK, Dalvi AN, Someshwar V, Supe AN, Ramakantan R. Endoscopic and radiological appraisal of gastric varices. Br J Surg. 1990;77(4):432-435.
7. Lewis JD, Faigel DO, Morris JB, Siegelman ES, Kochman ML. Splenic vein thrombosis secondary to focal pancreatitis diagnosed by endoscopic ultrasonography. J Clin Gastroenterol. 1998;26(1):54-56.
8. Erden A, Erden I, Yağmurlu B, Karayalçin S, Yurdaydin C, Karayalçin K. Portal venous system: evaluation with contrast-enhanced 3D MR portography. Clin Imaging. 2003;27(2):101-105.