How to manage gastric and ectopic varices?

Abstract

Gastric varices are present in about 20 % of cirrhotic patients with a low incidence of bleeding (10–36 %) but high rebleeding rates (34–89 %). The classification according to their location has an important role in the management. No guidelines are available for primary prophylaxis of gastric variceal bleeding but cyanoacrylate glue seems to be more effective than beta-blockers. Treatment of acute hemorrhage may be performed by tissue adhesives injection, thrombin injection, endoscopic sclerotherapy, variceal band, and loop ligation. In case of failure to control acute bleeding, rescue radiologic approaches include TIPS, balloon-occluded retrograde transvenous obliteration (BRTO), balloon-occluded endoscopic injection sclerotherapy (BOIS), balloon-occluded antegrade transvenous obliteration (BATO). Surgery may be indicated only when all other techniques have failed in patients with Child-Turcotte-Pugh class A cirrhosis or in patients who live at a great distance from centers that can adequately manage variceal bleeding. In the setting of secondary prophylaxis endoscopic therapy is better than drug therapy and the use of tissue adhesive is the modality of choice; there are also clear recommendations for the routine use of radiologic techniques, such as TIPS, BRTO, and BO-EIS. Ectopic varices (EcV) are dilated portosystemic collateral veins located in sites other than the gastroesophageal region and their bleeding constitutes 1–5 % of all variceal bleeds in patients with intrahepatic portal hypertension and 20–30 % of those with extrahepatic portal hypertension. No primary or secondary prophylaxis for EcV is recommended. The management of acute ectopic variceal bleed requires a multidisciplinary approach that includes pharmacological, endoscopic, and angiographic methods with surgery for highly selected cases.