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.

• Fever

  The patient developed mild fever and pain over the left upper quadrant and flank after the procedure. In addition to a Lipiodol-filled gastric varix, the imaging studies disclosed a wide spread of Lipiodol over the left peritoneal cavity. [ncbi.nlm.nih.gov]

• Surgical Procedure

  Splenectomy combined with other surgical procedures was undertaken for 15 patients. The patients undergoing artery embolization or splencetomy achieved hemostasis. The survivors had no recurrent bleeding during a median 72-month follow-up period. [ncbi.nlm.nih.gov]

  A surgical procedure that removes the bleeding varices. This procedure is done when a TIPS or a surgical shunt isn't possible or unsuccessful in controlling the bleeding. Esophageal transection. [webmd.com]

  The most commonly employed procedure today is a transjugular intrahepatic portosystemic shunt (TIPS), which is a non-surgical procedure performed by radiologists (see below). In rare circumstances, a surgical shunt may be necessary. [liver.ca]

  However, such a tube may provide life-saving tamponade pending decompression with a TIPS or surgical procedure. The tube is a flexible NGT with one gastric balloon and one esophageal balloon. [merckmanuals.com]

• Pallor

  Physical examination will likely reveal hypotension or shock (in severe cases), pallor and stigmata of chronic liver disease such as spider angiomatas, palmar erythema, gynecomastia, or splenomegaly. [clevelandclinicmeded.com]

• Aspiration

  Thirty to 50 minutes later, the outflow is coil-embolized and as much as possible of the remaining sclerosant is aspirated via the catheter before deflating the balloon and withdrawing the catheter. [massgeneral.org]

  To avoid bronco aspiration the patient must be with endotracheal tube. [gastrointestinalatlas.com]

  Arrest hemorrhage by solidify or aspirating varicosity. One of the three commonest cause of death by cirrhosis of liver. [tokushukai.or.jp]

  The procedure is quite uncomfortable and may result in esophageal perforation and aspiration; thus, endotracheal intubation and IV sedation are often recommended. [merckmanuals.com]

• 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

  Coronal CT of a 58-year-old male with alcoholic cirrhosis who presented with melena. (A) shows left renal vein (red arrow) and gastrorenal shunt (orange arrow) and (B) shows gastric varices (blue arrows), indicating suitable anatomy for BRTO. [massgeneral.org]

  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]

• Gastropathy

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

  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]

  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]

• Liver Dysfunction

  Size of GV, presence of red signs, and the degree of liver dysfunction are independent predictors of bleeding. [ncbi.nlm.nih.gov]

  The lack of impact on mortality may be attributed to the increased rate of hepatic encephalopathy and to liver dysfunction in the TIPS group, two of the patients in the TIPS group developed liver failure. [wjgnet.com]

  dysfunction) and surgeon skills (1,3). [scielo.isciii.es]

• Hypertension

  It is followed by a brief discussion regarding varices due to splenic venous hypertension. [ncbi.nlm.nih.gov]

• Erythema

  Look for the stimata of chronic liver disease on physical exam, including spider nevi, jaundice, palmar erythema, Dupuytren’s contractures, testicular atrophy, loss of secondary sexual characteristics, splenomegaly, ascites, encephalopathy (asterixis) [cancertherapyadvisor.com]

  Physical examination will likely reveal hypotension or shock (in severe cases), pallor and stigmata of chronic liver disease such as spider angiomatas, palmar erythema, gynecomastia, or splenomegaly. [clevelandclinicmeded.com]

• Withdrawn

  After 15 to 30 seconds once the CYA is solidified and the risk of bleeding by puncturing decreases, the needle will be withdrawn. Finally obliteration of the vessel will be evaluated using Doppler imaging 5 minutes later. [ichgcp.net]

  The needle is withdrawn and the area assessed for bleeding. The procedure can be repeated if the varix is large. Suction should not be used to avoid risk of suctioning glue that might be external to the varix. [nursingcenter.com]

  As the needle is withdrawn from varix, a steady stream of the flush solution is aimed at the puncture site. [ncbi.nlm.nih.gov]

• Encephalopathy

  It is suitable for patients with portosystemic shunts causing encephalopathy and for patients who are not candidates for TIPS because of a high MELD score. [massgeneral.org]

  No differences were found in survival or rebleeding, but the group treated with TIPS had an increased morbidity requiring prolonged hospitalization because of encephalopathy. [explainmedicine.com]

  The primary markers that need to be evaluated contained technical success rate, hemostasis rate, incidence rate of postoperative rebleeding, incidence rate of hepatic encephalopathy, and postoperative procedure-related complication. [ncbi.nlm.nih.gov]

  Hepatic encephalopathy refers to the worsening of brain function that is caused by a damaged liver. [cirse.org]

• Stroke

  The primary effect is atrial fibrillation, which results in stroke. Further Reading All Gastric Varices Content Gastric Varices Gastric Varices - Signs and Symptoms Sarin Classification of Gastric Varices [news-medical.net]

  Stroke after varicose vein foam injection sclerotherapy. J Vasc Surg 2006; 43:162–164 [Google Scholar] 59. Morrison N, Neuhardt DL, Rogers CR, et al. Comparisons of side effects using air and carbon dioxide foam for endovenous chemical ablation. [ajronline.org]

  Complications Complications are mainly thrombotic in nature and include cerebral embolization and stroke, portal vein embolization, splenic infarction, coronary emboli, with a series demonstrating fatal and nonfatal pulmonary emboli in up to 5% of cases [ncbi.nlm.nih.gov]

• Confusion

  Even after the bleeding has been stopped, there can be serious complications, such as pneumonia, sepsis, liver failure, kidney failure, confusion, and coma. [webmd.com]

  Because of this some people who have had a TIPS procedure develop symptoms of confusion, called encephalopathy. Medication can reduce symptoms of encephalopathy. External resources American College of Gastroenterology (ACG) P.O. [drugs.com]

  The rugal fold pattern of a hiatal hernia may be confused with esophageal varices; however, a hiatal hernia can be identified easily by the presence of the B line marking the gastroesophageal junction. [emedicine.medscape.com]

  It is important to note that these studies included patients at the time of the index bleeding which could be confusing in terms of overlap with treatment of acute bleeding, but patients with uncontrolled bleeding were excluded. [wjgnet.com]

  There was also evidence of heterogeneity (called inconsistency in the GRADE system; not to be confused with inconsistency in direct and indirect estimates in the context of network meta‐analysis) for serious adverse events (number of participants), and [cochranelibrary.com]

• Irritability

  […] reported, but there has not been a single established effective method yet. 18 ) The mechanism of the action of a sclerosant is unclear but, in intravariceal injection, its use produces a variable combination of intimal injury, initiated by its direct irritant [kjim.org]

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].

• Atelectasis

  Any plain radiographic findings suggesting paraesophageal varices should be followed up with CT scanning or a barium study to differentiate the findings from a hiatal hernia, posterior mediastinal mass, or other abnormality (eg, rounded atelectasis). [emedicine.medscape.com]

• Hepatocellular Carcinoma

  Contrast-enhanced CT revealed gastric varices and hepatocellular carcinoma with tumor thrombi in the right portal vein. [ncbi.nlm.nih.gov]

  Concomitant hepatocellular carcinoma may also be a risk factor for hemorrhage ( Irani, Kowdley, & Kozarek, 2011 ). [nursingcenter.com]

(B) Blue arrows on axial images indicate gastric varices before treatment (A) and their absence after treatment. Coronal images in (C) show varices (blue arrow) before treatment. (D) shows artifact from coils (orange arrow) in post-treatment CT. [massgeneral.org]

Pharmacologic treatment (including terlipressin, somatostatin or octreotide) for variceal bleeding in cirrhosis are beneficial as first-line treatment [1] Treatment of acute bleeding - Prophylactic antibiotics [1] Prophylactic antibiotics should be administrated [explainmedicine.com]

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

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]

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

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]

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]

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. Hepatology 2007;46:922-38. 2. Qureshi W, Adler DG, Davila R, Egan J, Hirota W, Leighton J, et al. [jdeonline.in]

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]

In the United States, the primary approach to prevent re-bleeding is the use of a transjugular intrahepatic postosystemic shunt (TIPS) to decompress the portal circulation. [massgeneral.org]

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