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Gastric Varices

Gastric varices (GV) are a type of upper gastrointestinal bleed, that are often associated with liver cirrhosis, portal hypertension or splenic vein thrombosis. GV are known to cause bleeding more severely than esophageal varices.


Presentation

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 75-year-old male presented with hematemesis and melena. Esophagogastroduodenoscopy revealed isolated gastric varices. A CT scan revealed a mass predominantly involving the spleen and a small part of the pancreas.[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • A 50-year-old female with a history of alcoholic liver disease was referred to our hospital because of hematemesis. Emergency endoscopic sclerotherapy was performed to control bleeding gastric varices.[ncbi.nlm.nih.gov]
  • A patient presented with hematemesis due to gastric variceal bleeding with an intratumoral arterioportal shunt. Contrast-enhanced CT revealed gastric varices and hepatocellular carcinoma with tumor thrombi in the right portal vein.[ncbi.nlm.nih.gov]
Melena
  • A 75-year-old male presented with hematemesis and melena. Esophagogastroduodenoscopy revealed isolated gastric varices. A CT scan revealed a mass predominantly involving the spleen and a small part of the pancreas.[ncbi.nlm.nih.gov]
  • 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]
  • A 50-year-old male with a history of transfusion-requiring erosive gastritis and recently diagnosed AIP on steroid therapy for 2 weeks presented with a 2-day history of lightheadedness, abdominal pain, and melena.[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]
  • […] in the majority of instances, the local spread will be such that resection through uninvolved tissue will be impossible. 1, 3 It is the purpose of this report to present an unusual case of carcinoma of the tail of the pancreas, manifested by massive melena[annals.org]
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]
Epigastric Pain
  • RESULTS: The mean number of BL sessions was 2.2 0.8; post-BL ulceration occurred in two (4%) patients (n 2 in IGV1, P 0.61), bleeding occurred in one (2%) patient (n 1 in IGV1, P 0.79), and epigastric pain occurred in six (12%, n 4 in GOV2, n 2 in IGV1[ncbi.nlm.nih.gov]
  • Only minor complications were observed, which were as follows: fever 38 C in 6 patients, epigastric pain in 8 patients, and temporary hypertension in 2 patients.[ncbi.nlm.nih.gov]
  • The mean number of BL sessions was 2.2 0.8; post-BL ulceration occurred in two (4%) patients ( n 2 in IGV1, P 0.61), bleeding occurred in one (2%) patient ( n 1 in IGV1, P 0.79), and epigastric pain occurred in six (12%, n 4 in GOV2, n 2 in IGV1) patients[journals.lww.com]
  • As complications, epigastric pain occurred in 19 cases (59.4%), fever in 10 cases (31.3%) and oozing from ulcer in 4 cases (12.5%).[kjim.org]
Maroon Stools
  • The symptoms can include vomiting blood, melena (passing black, tarry stools); or passing maroon stools or frank blood in the stools. Many people with bleeding gastric varices present in shock due to the profound loss of blood.[en.wikipedia.org]
Back Pain
  • A 65-year-old Japanese man was hospitalized with back pain in April 1998. At age 63 years, endoscopic ablation with cyanoacrylate glue had been performed for bleeding gastric varices.[ncbi.nlm.nih.gov]
  • Minor complications commonly include epigastric and back pain, and transient hemoglobinuria. Portal venous pressures will increase after BRTO. BRTO leads to aggravation of esophageal varices in 30-68% of cases and worsening ascites in 42% of cases.[massgeneral.org]
  • Epigastric and back pain, fever, and hematuria were most common, often found in a large percentage of patients [ 15 – 18, 21, 42, 46 ].[ajronline.org]

Workup

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].
Liver Biopsy
  • CT venography, endoscopic ultrasound and transjugular liver biopsy. Nodular regenerative hyperplasia of the liver leading to gastric varices.[ncbi.nlm.nih.gov]
  • Splenectomy was performed and near normal wedge liver biopsy pathology confirmed non-cirrhotic extrahepatic portal hypertension. The patient had no further variceal bleeding after surgery.[ncbi.nlm.nih.gov]
  • The current gold standard for diagnosing liver fibrosis and cirrhosis is histological analysis of tissue obtained through liver biopsy.[bmcgastroenterol.biomedcentral.com]
  • The liver biopsy ruled out infiltrative, cirrhotic, or thrombotic process.[cureus.com]
  • Interventions, such as transvenous liver biopsy and the TIP shunt (TIPS) procedure, may be performed by using this approach. Complications of the procedure are minimal, with a small possibility of infection and bleeding at the venipuncture site.[emedicine.medscape.com]

Treatment

  • These two patient groups were compared as regards content of treatment, post-treatment incidence of variceal bleeding, incidence of IGV rebleeding, survival rate, cause of death, and complications.[ncbi.nlm.nih.gov]
  • Recently, the application of interventional EUS has been expanded to a new field, the treatment of gastrointestinal varices. There have been several studies examining this new technique for the treatment of esophageal and gastric varices.[ncbi.nlm.nih.gov]
  • We basically applied endoscopic glue embolization using cyanoacrylate monomer for treatment of acute bleeding.[ncbi.nlm.nih.gov]
  • Splenectomy is the preferred long-term standard treatment for non-orthotopic liver transplantation patients, but additional treatments such as post-transplantation partial splenic arterial embolization to preserve the immunological function of the spleen[ncbi.nlm.nih.gov]
  • Endoscopic treatment of these varices is often warranted to prevent catastrophic bleeding.[ncbi.nlm.nih.gov]

Prognosis

  • Given the extremely poor prognosis of pancreatic adenocarcinoma, early diagnosis is crucial; however, clinical signs and symptoms of the disease are neither sensitive nor specific.[ncbi.nlm.nih.gov]
  • The underlying cause determines the clinical significance and prognosis of HPVG.[ncbi.nlm.nih.gov]
  • However, additional endoscopic sclerotherapy may be needed to eliminate the variceal feeding vessels to further improve the long-term prognosis of these patients.[ncbi.nlm.nih.gov]
  • […] significantly with liver function (hazard ratio 2.371, 95% CI 1.457-3.860, P   0.001) and hepatocellular carcinoma development (HR 4.782, 95% CI 2.331-9.810, P CONCLUSION: B-RTO for GV could provide the high rate of complete obliteration and favorable long-term prognosis[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]

Etiology

  • 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]
  • Eight patients with findings of gastric submucosal lesions of uncertain etiology on EGD. EGD with DOP-US examination, with or without standard EUS. Presence or absence of audible DOP-US signal and EUS findings for gastric submucosal lesions.[ncbi.nlm.nih.gov]
  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[aapc.com]
  • Hepatitis C was the most common etiology, found in 63 (65%) patients. The majority of the patients were classified as Child-Pugh grade B and C: 44 (46%) and 29 (31%) patients, respectively.[ncbi.nlm.nih.gov]

Epidemiology

  • 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]
Sex distribution
Age distribution

Pathophysiology

  • 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]
  • Early steroid treatment should be considered in patients with uncomplicated AIP to prevent the occlusive vascular complications that are frequently associated with the pathophysiology of this disease process.[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]

Prevention

  • 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]
  • […] the preferred long-term standard treatment for non-orthotopic liver transplantation patients, but additional treatments such as post-transplantation partial splenic arterial embolization to preserve the immunological function of the spleen and thus prevent[ncbi.nlm.nih.gov]
  • Herein, we present a patient who developed splenic infarction after N-butyl-cyanoacrylate injection for gastroesophageal varices type 2 and discuss the potential reasons and tips to prevent the occurence of embolization.[ncbi.nlm.nih.gov]
  • Endoscopic treatment of these varices is often warranted to prevent catastrophic bleeding.[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]

References

Article

  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.

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Last updated: 2019-06-28 12:20