Beyond the scope and the glue: update on evaluation and management of gastric varices
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REVIEW
Beyond the scope and the glue: update on evaluation and management of gastric varices Cyriac Abby Philips1* , Rizwan Ahamed2, Sasidharan Rajesh3, Tom George3, Meera Mohanan4 and Philip Augustine2
Abstract Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes. Conventionally, gastric varices have been described based on the location and extent and endoscopic treatments offered based on these descriptions. With improved understanding of portal hypertension and the dynamic physiology of collateral circulation, gastric variceal classification has been refined to include inflow and outflow based hemodynamic pathways. These have led to an improvement in the management of gastric variceal disease through newer modalities of treatment such as endoscopic ultrasound-guided glue-coiling combination therapy and the emergence of highly effective endovascular treatments such as shunt and variceal complex embolization with or without transjugular intrahepatic portosystemic shunt (TIPS) placement in patients who are deemed ‘difficult’ to manage the traditional way. Furthermore, the decisions regarding TIPS and additional endovascular procedures in patients with gastric variceal bleeding have changed after the emergence of ‘portal hypertension theories’ of proximity, throughput, and recruitment. The hemodynamic classification, grounded on novel theories and its cognizance, can help in identifying patients at baseline, in whom conventional treatment could fail. In this exhaustive review, we discuss the conventional and hemodynamic diagnosis of gastric varices concerning new classifications; explore and illustrate new ‘portal hypertension theories’ of gastric variceal disease and corresponding management and shed light on current evidence-based treatments through a ‘new’ algorithmic approach, established on hemodynamic physiology of gastric varices. Keywords: Endoscopy, EUS, Bleeding, Cirrhosis, Portal hypertension, Portal vein, TIPS, BRTO, CARTO, PARTO Disease definition and epidemiology Portal hypertension (PH) is a syndrome characterized by the formation of portosystemic collaterals in the presence or absence of cirrhosis. The cardinal feature of PH is the formation of varices, which are dilated preexisting or newly formed portosystemic venous channels, commonly found in esophageal and gastric regions that at risk for gastrointestinal bleeding. The prevalence *Correspondence: [email protected] 1 The Liver Unit and Monarch Liver Laboratory, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala 682028, India Full list of author information is available at the end of the article
of varices in cirrhosis can range from 40% in patients with Child–Pugh class A to approximately 85% in those in Child–Pugh class C [1, 2]. Gastric varices (GV; commonly classified using the Sarin system) are less common than esophageal varices with an incidence between 2 and 20%. As a general rule, GV is note
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