Gastric varices

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Gastric varices
Gastric varices.jpg
Isolated gastric varices of Sarin classification IGV-1 seen on gastroscopy in a patient with portal hypertension
Specialty Gastroenterology Hematology
Symptoms vomiting blood passing black stool
Complications Internal bleeding, hypovolemic shock, cardiac arrest

Gastric varices are dilated submucosal veins in the lining of the stomach, which can be a life-threatening cause of bleeding in the upper gastrointestinal tract. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis. Gastric varices may also be found in patients with thrombosis of the splenic vein, into which the short gastric veins that drain the fundus of the stomach flow. The latter may be a complication of acute pancreatitis, pancreatic cancer, or other abdominal tumours, as well as hepatitis C. Gastric varices and associated bleeding are a potential complication of schistosomiasis resulting from portal hypertension.

Contents

Patients with bleeding gastric varices can present with bloody vomiting (hematemesis), dark, tarry stools (melena), or rectal bleeding. The bleeding may be brisk, and patients may soon develop shock. Treatment of gastric varices can include injection of the varices with cyanoacrylate glue, or a radiological procedure to decrease the pressure in the portal vein, termed transjugular intrahepatic portosystemic shunt or TIPS. Treatment with intravenous octreotide is also useful to shunt blood flow away from the stomach's circulation. More aggressive treatment, including splenectomy (surgical removal of the spleen) or liver transplantation, may be required in some cases.

Signs and symptoms

Axial CT showing varices of the fundus in liver cirrhosis with portal hypertension Fundusvarizen.jpg
Axial CT showing varices of the fundus in liver cirrhosis with portal hypertension

Gastric varices can present in two major ways. First, patients with cirrhosis may be enrolled in screening gastroscopy programs to detect esophageal varices. These evaluations may detect gastric varices that are asymptomatic. When gastric varices are symptomatic, however, they usually present acutely and dramatically with upper gastrointestinal bleeding. The symptoms can include vomiting blood, melena (passing black, tarry stools); or passing maroon stools or frank blood in the stools. Many people with bleeding gastric varices present in shock due to the profound loss of blood. [1]

Secondly, patients with acute pancreatitis may present with gastric varices as a complication of a blood clot in the splenic vein. The splenic vein sits over the pancreas anatomically. Inflammation or cancers of the pancreas may result in a blood clot forming in the splenic vein. As the short gastric veins of the fundus of the stomach drain into the splenic vein, thrombosis of the splenic vein will result in increased pressure and engorgement of the short veins, leading to varices in the fundus of the stomach.[ citation needed ]

Laboratory testing usually shows low red blood cell count and often a low platelet count. If cirrhosis is present, there may be coagulopathy manifested by a prolonged INR; both of these may worsen the bleeding from gastric varices. [2]

In rare cases, gastric varices are caused by splenic vein occlusion as a result of the mass effect of slow-growing pancreatic neuroendocrine tumors.[ citation needed ]

Diagnosis

The diagnosis of gastric varices is often made at the time of upper endoscopy. [1]

The Sarin classification of gastric varices identifies two types of gastroesophageal varices, where esophageal varices are found concurrently, and two types of isolated gastric varices, found in the absence of esophageal varices. Sarin classification.jpg
The Sarin classification of gastric varices identifies two types of gastroesophageal varices, where esophageal varices are found concurrently, and two types of isolated gastric varices, found in the absence of esophageal varices.

Classification

Antral varices, of Sarin classification IGV-2, an unusual class of gastric varices. Antral varices.jpg
Antral varices, of Sarin classification IGV-2, an unusual class of gastric varices.

The Sarin classification of gastric varices identifies four different anatomical types of gastric varices, which differ in terms of treatment modalities: [1]

Type 1 isolated gastric varices were seen only in primary cases (i.e. without prior sclerotherapy) in the original study of Sarin et al. (1992), while type 1 gastroesophageal varices were the most common overall. [3]

Other classification systems include Hashizume's classification and Arakawa's classification. [1]

Treatment

Initial treatment of bleeding from gastric varices focuses on resuscitation, much as with esophageal varices. This includes administration of fluids, blood products, and antibiotics. [4] [5]

Another treatment for gastric varices is injection of the varices with cyanoacrylate, first described by German surgeon Nib Soehendra and colleagues in 1986. [6] The results from two randomized trials comparing band ligation vs cyanoacrylate suggests that endoscopic injection of cyanoacrylate, known as gastric variceal obliteration or GVO is superior to band ligation in preventing rebleeding rates. Cyanoacrylate, a common component in 'super glue' is often mixed 1:1 with lipiodol to prevent polymerization in the endoscopy delivery optics, and to show on radiographic imaging. GVO is usually performed in specialized therapeutic endoscopy centers. Complications include sepsis, embolization of glue, and obstruction from polymerization in the lumen of the stomach.[ citation needed ]

Other techniques for refractory bleeding include: [5]

See also

Related Research Articles

<span class="mw-page-title-main">Gastroenterology</span> Branch of medicine focused on the digestive system and its disorders

Gastroenterology is the branch of medicine focused on the digestive system and its disorders. The digestive system consists of the gastrointestinal tract, sometimes referred to as the GI tract, which includes the esophagus, stomach, small intestine and large intestine as well as the accessory organs of digestion which include the pancreas, gallbladder, and liver.

<span class="mw-page-title-main">Upper gastrointestinal bleeding</span> Medical condition

Upper gastrointestinal bleeding is gastrointestinal bleeding (hemorrhage) in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit or in altered form as black stool. Depending on the amount of the blood loss, symptoms may include shock.

Hematemesis is the vomiting of blood. It can be confused with hemoptysis or epistaxis (nosebleed), which are more common. The source is generally the upper gastrointestinal tract, typically above the suspensory muscle of duodenum. It may be caused by ulcers, tumors of the stomach or esophagus, varices, prolonged and vigorous retching, gastroenteritis, ingested blood, or certain drugs.

Coffee ground vomitus refers to a particular appearance of vomit. Within organic heme molecules of red blood cells is the element iron, which oxidizes following exposure to gastric acid. This reaction causes the vomitus to look like ground coffee.

<span class="mw-page-title-main">Esophagogastroduodenoscopy</span> Diagnostic endoscopic procedure

Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered a minimally invasive procedure since it does not require an incision into one of the major body cavities and does not require any significant recovery after the procedure. However, a sore throat is common.

<span class="mw-page-title-main">Esophageal varices</span> Medical condition

Esophageal varices are extremely dilated sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis. People with esophageal varices have a strong tendency to develop severe bleeding which left untreated can be fatal. Esophageal varices are typically diagnosed through an esophagogastroduodenoscopy.

<span class="mw-page-title-main">Portal hypertension</span> Abnormally increased portal venous pressure

Portal hypertension is defined as increased portal venous pressure, with a hepatic venous pressure gradient greater than 5 mmHg. Normal portal pressure is 1–4 mmHg; clinically insignificant portal hypertension is present at portal pressures 5–9 mmHg; clinically significant portal hypertension is present at portal pressures greater than 10 mmHg. The portal vein and its branches supply most of the blood and nutrients from the intestine to the liver.

<span class="mw-page-title-main">Gastrointestinal bleeding</span> Medical condition

Gastrointestinal bleeding, also called gastrointestinal hemorrhage (GIB), is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool. Small amounts of bleeding over a long time may cause iron-deficiency anemia resulting in feeling tired or heart-related chest pain. Other symptoms may include abdominal pain, shortness of breath, pale skin, or passing out. Sometimes in those with small amounts of bleeding no symptoms may be present.

<span class="mw-page-title-main">Splenic vein</span> Vein that drains blood from the spleen, stomach and pancreas

In human anatomy, the splenic vein is a blood vessel that drains blood from the spleen, the stomach fundus and part of the pancreas. It is part of the hepatic portal system.

<span class="mw-page-title-main">Transjugular intrahepatic portosystemic shunt</span> Artificial channel within the liver

Transjugular intrahepatic portosystemic shunt is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein. It is used to treat portal hypertension which frequently leads to intestinal bleeding, life-threatening esophageal bleeding and the buildup of fluid within the abdomen (ascites).

<span class="mw-page-title-main">Portal vein thrombosis</span> Disease of the liver

Portal vein thrombosis (PVT) is a vascular disease of the liver that occurs when a blood clot occurs in the hepatic portal vein, which can lead to increased pressure in the portal vein system and reduced blood supply to the liver. The mortality rate is approximately 1 in 10.

<span class="mw-page-title-main">Gastric antral vascular ectasia</span> Medical condition of the stomach

Gastric antral vascular ectasia (GAVE) is an uncommon cause of chronic gastrointestinal bleeding or iron deficiency anemia. The condition is associated with dilated small blood vessels in the pyloric antrum, which is a distal part of the stomach. The dilated vessels result in intestinal bleeding. It is also called watermelon stomach because streaky long red areas that are present in the stomach may resemble the markings on watermelon.

<span class="mw-page-title-main">Distal splenorenal shunt procedure</span> Medical procedure

In medicine, a distal splenorenal shunt procedure (DSRS), also splenorenal shunt procedure and Warren shunt, is a surgical procedure in which the distal splenic vein is attached to the left renal vein. It is used to treat portal hypertension and its main complication. It was developed by W. Dean Warren.

<span class="mw-page-title-main">Sengstaken–Blakemore tube</span> Medical device

A Sengstaken–Blakemore tube is a medical device inserted through the nose or mouth and used occasionally in the management of upper gastrointestinal hemorrhage due to esophageal varices. The use of the tube was originally described in 1950, although similar approaches to bleeding varices were described by Westphal in 1930. With the advent of modern endoscopic techniques which can rapidly and definitively control variceal bleeding, Sengstaken–Blakemore tubes are rarely used at present.

<span class="mw-page-title-main">Hemosuccus pancreaticus</span> Medical condition

Hemosuccus pancreaticus is a rare cause of hemorrhage in the gastrointestinal tract. It is caused by a bleeding source in the pancreas, pancreatic duct, or structures adjacent to the pancreas, such as the splenic artery, that bleed into the pancreatic duct, which is connected with the bowel at the duodenum, the first part of the small intestine. Patients with hemosuccus may develop symptoms of gastrointestinal hemorrhage, such as blood in the stools, maroon stools, or melena, which is a dark, tarry stool caused by digestion of red blood cells. They may also develop abdominal pain. It is associated with pancreatitis, pancreatic cancer and aneurysms of the splenic artery. Hemosuccus may be identified with endoscopy (esophagogastroduodenoscopy), where fresh blood may be seen from the pancreatic duct. Alternatively, angiography may be used to inject the celiac axis to determine the blood vessel that is bleeding. This may also be used to treat hemosuccus, as embolization of the end vessel may terminate the hemorrhage. However, a distal pancreatectomy—surgery to remove of the tail of the pancreas—may be required to stop the hemorrhage.

<span class="mw-page-title-main">Portal hypertensive gastropathy</span> Changes in the mucosa of the stomach in patients with portal hypertension

Portal hypertensive gastropathy refers to changes in the mucosa of the stomach in patients with portal hypertension; by far the most common cause of this is cirrhosis of the liver. These changes in the mucosa include friability of the mucosa and the presence of ectatic blood vessels at the surface. Patients with portal hypertensive gastropathy may experience bleeding from the stomach, which may uncommonly manifest itself in vomiting blood or melena; however, portal hypertension may cause several other more common sources of upper gastrointestinal bleeding, such as esophageal varices and gastric varices. On endoscopic evaluation of the stomach, this condition shows a characteristic mosaic or "snake-skin" appearance to the mucosa of the stomach.

<span class="mw-page-title-main">Butyl cyanoacrylate</span> Chemical compound

n-Butyl cyanoacrylate, a cyanoacrylate ester, is a butyl ester of 2-cyano-2-propenoic acid. It is a colorless liquid with a sharp, irritating odor. It is insoluble in water. Its chief use is as the main component of medical cyanoacrylate glues. It can be encountered under various trade names, e.g. Cutseal, MediBond, MediCryl, PeriAcryl, GluStitch, Xoin, Gesika, VetGlu, Vetbond, LiquiVet, Indermil, LiquiBand, Histoacryl, IFABond, CutisSeal and others. The generic international nonproprietary name (INN) for NBCA is enbucrilate.

Therapeutic endoscopy is the medical term for an endoscopic procedure during which treatment is carried out via the endoscope. This contrasts with diagnostic endoscopy, where the aim of the procedure is purely to visualize a part of the gastrointestinal, respiratory or urinary tract in order to aid diagnosis. In practice, a procedure which starts as a diagnostic endoscopy may become a therapeutic endoscopy depending on the findings, such as in cases of upper gastrointestinal bleeding, or the finding of polyps during colonoscopy.

The Sugiura procedure is a surgical technique that involves the removal and transection of the blood vessels that supply the upper portion of the stomach and the esophagus. The procedure also involves a splenectomy. The operation was originally developed to treat bleeding esophageal varices that were untreatable by other conventional methods. It was originally developed as a two-step operation, but has been modified numerous times by many surgeons since its original creation.

Balloon-occluded retrograde transvenous obliteration (BRTO) is an endovascular procedure used for the treatment of gastric varices. When performing the procedure, an interventional radiologist accesses blood vessels using a catheter, inflates a balloon and injects a substance into the variceal blood vessels that causes blockage of those vessels. To prevent the flow of the agent out of the intended site, a balloon is inflated during the procedure, which occludes.

References

  1. 1 2 3 4 Wani Z, Bhat R, Bhadoria A, Maiwall R, Choudhury A (December 2015). "Gastric varices: Classification, endoscopic and ultrasonographic management". Journal of Research in Medical Sciences. 20 (12): 1200–1207. doi: 10.4103/1735-1995.172990 . PMC   4766829 . PMID   26958057.
  2. ↑ "Cirrhosis". The Lecturio Medical Concept Library. 28 September 2020. Retrieved 9 July 2021.
  3. ↑ Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK (1992). "Prevalence, Classification and Natural History of Gastric Varices: A Long-term Follow-up Study in 568 Portal Hypertension Patients". Hepatology. 16 (6): 1343–1349. doi: 10.1002/hep.1840160607 . PMID   1446890.
  4. ↑ Goral, Vedat; Yılmaz, Nevin (3 July 2019). "Current Approaches to the Treatment of Gastric Varices: Glue, Coil Application, TIPS, and BRTO". Medicina. 55 (7): 335. doi: 10.3390/medicina55070335 . ISSN   1648-9144. PMC   6681371 . PMID   31277322.
  5. 1 2 Lee, Edward Wolfgang; Shahrouki, Puja; Alanis, Lourdes; Ding, Pengxu; Kee, Stephen T. (2019-06-01). "Management Options for Gastric Variceal Hemorrhage". JAMA Surgery. 154 (6): 540–548. doi:10.1001/jamasurg.2019.0407. ISSN   2168-6254. PMID   30942880. S2CID   93000660.
  6. ↑ Soehendra N, Nam VC, Grimm H, Kempeneers I (1986). "Endoscopic obliteration of large esophagogastric varices with bucrylate". Endoscopy. 18 (1): 25–6. doi:10.1055/s-2007-1013014. PMID   3512261.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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