Gastric varices are an important portosystemic collateral pathway, occurring in ~20% of patients with portal hypertension. They are considered distinct from esophageal varices in that they have a propensity to hemorrhage at comparatively lower portal pressures 1, and are also associated with higher mortality rate with haemorrhage (range 14-45%) 2.
Patients may present with symptoms and signs of upper gastrointestinal bleeding or hypovolemia such as:
- coffee-ground vomitus
Patients will generally have a history of cirrhosis and may have other symptoms of chronic liver disease.
Gastric varices occur due to elevated portal venous pressure, and represent a collateral flow pathway from the congested portal system to systemic veins. They commonly co-occur and may be continuous with esophageal varices 2,3.
The gastric varix itself usually represents a dilated left gastric or posterior gastric vein.
Afferent inflow is most commonly from 2:
- left gastric vein
- posterior gastric vein
- gastroepiploic vein (rare) - mostly occurring after prior intervention
Efferent outflow is most common through 2:
- gastro-renal shunt (to left renal vein)
- often communicates with small retroperitoneal veins
- may or may not communicate with the phrenico-pericardial or intercostal veins
- rarely communicates with the ascending lumbar, vertebral plexus, or azygous veins
- gastro-caval shunt (to suprarenal IVC)
- often communicates with the phrenicopericardial and intercostal veins
- rarely communicates with the azygous veins
- fundus-inferior phrenic vein
The most common (Sarin) classification scheme characterises gastric varices by their co-occurrence with esophageal varices and anatomic location 4:
- gastric and esophageal varices (GOV)
- type 1 (GOV1) - at lesser curvature
- type 2 (GOV2) - at gastric fundus
- isolated gastric varices (IGV)
- type 1 (IGV1) - at gastric fundus
- type 2 (IGV2) - other gastric or early duodenal location
In 2003, Kiyosue proposed a classification system intended to guide intervention by BRTO-type techniques. With this in mind, gastric varices may be characterised by inflow and outflow patterns:
Inflow pattern (following outflow occlusion)
- Type 1 - stagnant varices flow
- Type 2 - shifting flow between separate gastric varices
- Type 3 - continued efferent flow via separate draining vein, despite occlusion
- 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
Management of gastric varices is also distinct from esophageal varices due to the anatomy. Endoscopic clipping or sclerosing are typically first line treatments, although interventional radiology techniques such as TIPS and BRTO are important therapeutic adjuncts. Indeed, BRTO is first-line therapy for gastric variceal hemorrhage in some Asian countries 3.
- 1. Morrison JD, Mendoza-Elias N, Lipnik AJ, Lokken RP, Bui JT, Ray CE, Gaba RC. Gastric Varices Bleed at Lower Portosystemic Pressure Gradients than Esophageal Varices. (2018) Journal of vascular and interventional radiology : JVIR. 29 (5): 636-641. doi:10.1016/j.jvir.2017.10.014 - Pubmed
- 2. Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices. Part 1. Anatomic classification. (2003) Radiographics : a review publication of the Radiological Society of North America, Inc. 23 (4): 911-20. doi:10.1148/rg.234025044 - Pubmed
- 3. Gimm G, Chang Y, Kim HC, Shin A, Cho EJ, Lee JH, Yu SJ, Yoon JH, Kim YJ. Balloon-Occluded Retrograde Transvenous Obliteration versus Transjugular Intrahepatic Portosystemic Shunt for the Management of Gastric Variceal Bleeding. (2018) Gut and liver. doi:10.5009/gnl17515 - Pubmed
- 4. Kapoor A, Dharel N, Sanyal AJ. Endoscopic Diagnosis and Therapy in Gastroesophageal Variceal Bleeding. (2015) Gastrointestinal endoscopy clinics of North America. 25 (3): 491-507. doi:10.1016/j.giec.2015.03.004 - Pubmed