Description:

A 53-year old female with hepatitis C, alcohol abuse, and child C cirrhosis presented with hematemesis for one day. Vital signs on admission were a blood pressure of 100/66 and heart rate of 110. Laboratory results were hemoglobin: 10 g/dL, platelets: 89,000, and INR: 2.8. She had a previous history of esophageal varices without any bleeding or history of variceal banding. Initial management consisted of packed red blood cells, IV Octreotide, a proton pump inhibitor, antibiotics, fresh frozen plasma, vitamin K, Erythromycin. Emergent endoscopy was undertaken.
As the scope enters the gastroesophageal junction, an actively spurting vessel is seen at 2 o'clock on the screen in the cardia. Here is the retroflexed view also showing bleeding from the cardia. After evaluation of the rest of the stomach and duodenum to rule out concurrent lesions, the scope is now repositioned and the GE junction is evaluated with a direct head on view. The scope was urgently removed from the patient, a banding device mounted, and the patient's esophagus reintubated. A band ligator is carefully positioned to show a "red out” which is due to the blood spurting on the lens of the endoscope as well as the suction applied. After banding in the cardia, the varices in the esophagus are banded in a distal to proximal manner.
Sarin classified gastric varices into gastroesophageal varices type I where they extend into the lesser curvature, gastroesophageal varices type 2 where they extend to the fundus. Isolated gastric varices type I which are only found in the fundus, and isolated gastric varices type 2 which have extensions to ectopic areas in the stomach or duodenum.
The management of gastric variceal bleeding can be subdivided into acute bleeding and secondary prophylaxis.
There is limited literature on the management of gastric varices, but the most current recommendations are: gastroesophageal varices may be managed like esophageal varices with band ligation. Isolated gastric varices should be managed with endoscopic variceal obturation with N-butyl–cyanoacrylate injection when available. Otherwise, endoscopic variceal ligation is an option. Isolated gastric varices secondary to splenic vein thrombosis should be treated with splenectomy when possible. TIPS should be considered in uncontrolled fundic varices and rebleeding varices despite multiple therapies.
Treatment with IV proton pump inhibitor appears in some studies to have a reduction in rebleeding rates. Unlike esophageal varices, there are no studies to recommend the routine use of Terlipressin or Octreotide. Antibiotics is also recommended for Spontaneous Bacterial Peritonitis prophylaxis.
Secondary prophylaxis against rebleeding includes a repeat endoscopy in two to three weeks and TIPSS or balloon occluded retrograde transvenous obliteration (BRTO) in the presence of gastrorenal shunts.

Contributed By:

Lauren Layer, University of Texas Medical Branch

Sathya Jaganmohan, MD, University of Texas Medical Branch

Gottumukkala S. Raju, M.D., MD Anderson Cancer Center

Andrew W. DuPont, M.D., University of Texas Medical Branch