Gastric varices

Gastric varices can present in two major ways. First, patients with cirrhosis may be enrolled in screening gastroscopy programs to detect esophageal varices. These evaluations may detect gastric varices that are asymptomatic. When gastric varices are symptomatic, however, they usually present acutely and dramatically with upper gastrointestinal bleeding. 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. In rare cases, gastric varices are caused by splenic vein occlusion as a result of the mass effect of slow-growing pancreatic neuroendocrine tumors. ==Diagnosis==

The diagnosis of gastric varices is often made at the time of upper endoscopy. • Type 1 Gastroesophageal Varices: Esophagus extending to lesser curvature of stomach • Type 2 Gastroesophageal Varices: Esophagus extending to greater curvature of stomach • Type 1 Gastric Varices: Isolated to the fundus • Type 2 Gastric Varices: Anywhere in the stomach, or duodenum Type 1 isolated gastric varices were seen only in primary cases (i.e. without prior sclerotherapy) in the original study of Sarin et al. (1992), while type 1 gastroesophageal varices were the most common overall. Other classification systems include Hashizume's classification and Arakawa's classification. ==Treatment==

Initial treatment of bleeding from gastric varices focuses on resuscitation, much as with esophageal varices. This includes administration of fluids, blood products, and antibiotics. Another treatment for gastric varices is injection of the varices with cyanoacrylate, first described by German surgeon Nib Soehendra and colleagues in 1986. The results from two randomized trials comparing band ligation vs cyanoacrylate suggests that endoscopic injection of cyanoacrylate, known as gastric variceal obliteration or GVO is superior to band ligation in preventing rebleeding rates. 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. GVO is usually performed in specialized therapeutic endoscopy centers. Complications include sepsis, embolization of glue, and obstruction from polymerization in the lumen of the stomach. Other techniques for refractory bleeding include: • Transjugular intrahepatic portosystemic shunts (TIPS) • Balloon occluded retrograde transvenous obliteration techniques (BRTO) • Coil-assisted retrograde transvenous obliteration (CARTO) • Gastric variceal ligation, although this modality is falling out of favour • Intra-gastric balloon tamponade as a bridge to further therapy • a caveat is that a larger balloon is required to occupy the fundus of the stomach where gastric varices commonly occur • Liver transplantation ==See also==