Gastric Varices

Raymond Li HMO2
A case of upper GI bleeding
71 Y M traveller from WA presented to Rosebud ED w/ melaena and
dizziness
• 2/7 of dark, tarry stools
• Nil abdominal pain, no nausea or vomiting
• Similar episode 4 months prior – no cause found on gas+colon
• Initial Hb = 58 g/L; Urea 13.7
• PHx: myelofibrosis, IHD
• Meds: ruxolitinib, CPI 0610-04 (myelofibrosis trial drug)
• SHx: indep, home with wife, nonsmoker, 4 std drinks per night usually, 8 stds while in VIC
• O/E: BP 143/56; HR 70; afebrile; on RA; abdo SNT
Management
• 1 unit pRBC transfused, and PPI bolus + infusion commenced
• Pt was transferred to FH
• Transfused further 2 units pRBC
• Hb 58 > 70
• Proceeded to gastroscopy
Single lesion seen in the fundus Injected with adrenaline
Diagnosed as Forrest IIa peptic ulcer Thermal therapy attempted but abandoned
(Non-bleeding visible vessel) due to instability of the scope
?GIST ?varices

Case was discussed amongst the gastroenterology team

• Consensus that features of the lesion more concerning for GIST than an ulcer
A previous MRI spleen showed gastro-oesophageal varices
• A CT chest, abdomen, and pelvis with portal venous phase was ordered
In the meantime, there were no further signs of UGIB
CT abdomen C+
Axial
CT abdomen C+
Coronal
CT findings
• Gastric varices with likely recent haemorrhage.
• Enlarged gastro-oesophageal varices adjacent to the cardia and fundus of the
stomach. Hyperdense material within the fundus of the stomach may represent
either haemorrhage or further varices.
• No solid gastric mass identified or evidence of metastatic disease.
• Imaging features of portal hypertension.
• Markedly enlarged spleen measuring up to 20 cm. Mild hepatomegaly.
Recanalisation of ligamentum teres.
Case was discussed with interventional radiology
• Planned for balloon-occluded retrograde transvenous obliteration (BRTO)
Portal hypertension in PMF
• Fibrosis of bone marrow results in extramedullary hematopoiesis –
particularly in liver and spleen
• Splenomegaly is a hallmark of PMF, hepatomegaly less common
• Portal hypertension develops as:
• Splenoportal blood flow is massively increased
• Intrahepatic vascular resistance is increased
• Possibility of portal vein thrombosis
• Sequelae of portal HTN then follow
• Ascites, oesophageal and gastric varices, GI bleeding, HE
Gastric varices
• Gastric varices are present in 5-33% of portal HTN patients
• Compared to presence of oesophageal varices in 30-70% cases of cirrhosis
• Gastric varices bleed less frequently than oesophageal
• However gastric variceal bleeding carries greater mortality – large size and
rapid flow
• They are classified endoscopically
 Classification
Gastro-oesophageal varices – gastric varices contiguous
with oesophageal varices
• GOV1: located along the lesser curvature of the
stomach
• EBL or cyanoacrylate injection can be used
• GOV2: extends along the greater curvature to the
gastric fundus
Isolated gastric varices
• IGV1: located at the fundus
• IGV2: located elsewhere
• Highest risk of haemorrhage (78%)

Kiyosue et al. 2013

Treatment
• Pharmacotherapy
• Vasoactive medications to decrease portal blood flow
• Octreotide or terlipressin
• Endoscopic
• Cyanoacrylate injection
• CA glue immediately polymerises into a firm clot when introduced into variceal lumen
• Safer and more effective than band ligation
• Variceal band ligation
• Effective in stopping acute bleeding, however rebleeding is common
• Other: thrombin injection, elastic bands and detachable snares, haemostatic sprays
• Interventional radiologic
• TIPS
• Rescue TIPS in patients that fail endoscopic treatment of acute haemorrhage
• Early TIPS for high-risk patients (e.g. Child-Pugh C)
• Balloon-occluded retrograde transvenous obliteration (BRTO) and variations
• Good long-term control of bleeding (90%), but 10% technical failure described
• May be combined with TIPS
Endoscopic Cyanoacrylate Injection Versus Balloon ‐Occluded
Retrograde Transvenous Obliteration for Prevention of Gastric Variceal
Bleeding: A Randomized Controlled Trial
Luo X et al. 2021 doi:10.1002/hep.31718
P: Patients with cirrhosis and history of bleeding from GOV2 or IGV1
I: BRTO (n=32)
C: Endoscopic cyanoacrylate injection (n=32)
O: Primary outcomes of gastric variceal rebleeding or all-cause rebleeding
• Mean follow-up time of ~27 months in both groups
• The probability of gastric variceal rebleeding was significantly higher in the CA injection group
than in the BRTO group (p = 0.024)
• The 1-year and 2-year cumulative probability of remaining free of all-cause rebleeding was also
significantly higher in the BRTO group than in the CA injection group
• The probability after 1 and 2 years was 96.3% and 92.6% in the BRTO group and 77% and 65.2% in
the cyanoacrylate injection group (p = 0.004)
• No significant difference in complication rate or mortality
 Anatomy
2 Venous systems involved in gastric varices
• Gastro-oesophageal venous system
• Anastomoses of left gastric v. tributaries
and oesophageal venous plexus
• Gastro-phrenic venous system
• Anastomoses of the gastric vv. of the
posterosuperior gastric wall and the
inferior phrenic vein
• The left IPV can terminate either into the
left renal v. or the IVC

Kiyosue et al. 2013

Gastro-oesophageal venous system Gastro-phrenic venous system
Portal antegrade venogram
Varix
Flow into anastomosis
Retrograde balloon
Post-op
• Embolisation was achieved with injection of glue-lipiodol mixture and
sclerosant
• Pt was monitored overnight and discharged the next morning
• Advised not to fly for 72 hours
• Follow-up portal venous CT abdomen in 1/12
• Ruxolitinib withheld until haematologist review
• Trial drug also withheld
• Pantoprazole 40mg BD for 2 weeks, then 40mg daily
• Alcohol cessation