By Jeyashree Sundaram (MBA)
Through the portal vein, the blood reaches the liver from spleen and intestines. In cirrhosis patients, there could be impairment in the normal blood flow. The small blood vessels in the esophagus or stomach will reroute the blood that comes from intestines around the liver. As a result, some of the blood vessels may become swollen and large.
These blood vessels are termed as varices. Though varices can happen anywhere in the gastrointestinal tract, stomach and esophagus are the most common places. In the situations, such as in portal hypertension where the blood pressure is high, the walls of the blood vessels may become thin. When the blood vessels rupture, blood will bleed in the upper portion of the gastrointestinal tract.
Categorization of Gastric Varices
Out of all the hemorrhage happening in the varices, gastric varices (GVs) contribute about 10-30%. Subsequent to spontaneous hemostasis, there tend to be about 35-90% of re-bleeding. The incidence of GV among patients with cirrhosis of liver is about 50% showing a correlation with the liver disease severity. GV is seen in approximately 20% of patients suffering from portal hypertension.
There are 3 classifications that exist for GV. They are:
- Sarin's classification,
- Hashizome classification, and
- Arakawa's classification
Depending upon the location in the stomach and its association with esophageal varices, GV is categorized as Sarin's classification. This most frequently used classification is divided further into 4 types depending upon its location in the stomach and the relationship it shared with esophageal varices.
- Gastroesophageal varix (GOV) type 1
- Gastroesophageal varix (GOV) type 2
- Isolated gastric varix (IGV) type 1
- Isolated gastric varix type 2
As GOV type 1 and type 2 are considered as esophageal varices’ extensions, the management of GOV types is similar to that of esophageal varices. Of all the GVs, GOV type accounts for 74% making it the most common type. IGV type 1 stands first in terms of bleeding incidences and GOV type 2 takes up the second place. The size of varices is the important factor predicted for hemorrhage.
There are 3 types in this classification which are based on the form, location, and color. The form type of GV is classified as Tortuous, Nodular, and Tumorous. Location type of GV is classified into 5 types based on the hemodynamic factors: Anterior, Posterior, Lesser curvature, Greater curvature of the cardia, and fundic area. GV is classified into red or white based on the color. The glossy appearance of the red color in the thin wall of the varix is termed as RC spot or red color spot.
There are 2 types in this classification. When the fundic varix is formed by a single supplying vessel, it is classified as Type 1(a). When more than one supplying vessel joins together to form a varix then it is Type 1(b). Type 2 categorization occurs when the communication of the varix is observed with other stomach wall vessels apart from the major supplying vessels.
Diagnosis and Treatment
Endoscopy is used for diagnosing GV. In cases of doubt, endoscopic ultrasound is performed for confirmation of GV. Computed tomography scan (with contrast), transabdominal ultrasound with Doppler, interventional angiography, magnetic resonance angiography, and portovenography are also used for diagnosis.
Risk factors of heavy bleeding include the presence of ascites, high portal pressure, advanced chronic liver disease, large size (of the varices), and red color spot. When a nipple or venous plug is present in the varix, it is associated with a significant risk of rupture of the site.
When compared with esophageal varices, GV differs in natural history, morphology, and pathophysiology. GV is rare occurring in about 33% of cases. Comparatively, the incidence of bleeding is low but it is also severe; mortality rates are higher than esophageal varices. 80% of bleeding in GV is linked to fundal varices.
GVs are larger, wider, and are found deeper in the region of submucosa. For these reasons, treatments such as sclerotherapy and band ligation used for esophageal varices are not found to be effective for GV. When patients are diagnosed for the risk of blood vessel ruptures, physicians prescribe beta blockers which will decrease the pressure in the varices and rupture may be prevented.
Upon gastric variceal bleeding, patients are admitted immediately in the hospital. Treatments such as intravenous fluids, red blood cell transfusion are carried out for supporting blood pressure. When patients have aberrations of blood clotting systems, platelets transfusion is required. Medication such as octreotide is used to stop bleeding. These intravenous medications decrease the blood pressure in the portal venous system. In emergencies, endoscopic therapy is used. As a final step, all the patients will receive antibiotic therapy as the use of antibiotics decreases the relapse risk upon controlling the bleeding. Antibiotics also prevent any infections that may arise and decrease mortality rates. GVs are best managed with glue injection such as histacryl, whenever therapy is required.