How Should Isolated Gastric Fundal Varices Be Treated?

We read with interest the article by Seewald et al. on recent progress in the management of esophagogastric varices [1]. When treating gastric varices, we should take into account the fact that the behavior of these varices varies according to their location. Because most isolated fundal varices originate from the short and/or posterior gastric veins, and drain into a developed gastrorenal shunt, the portal venous pressure in patients with large fundal varices is quite low, whereas the collateral flow into the fundal varices is abundant [2].

Transjugular intrahepatic portosystemic shunt (TIPS) is considered to be a rescue option for variceal bleeding unresponsive to pharmacological and endoscopic treatment [1]. However, Tripathi and colleagues showed that gastric variceal bleeding was likely to occur at a portal pressure gradient of less than or equal to 12 mm Hg, while TIPS only improved the mortality rate in patients with gastric variceal bleeding at a portal pressure gradient that was greater than 12 mm Hg [3]. Therefore, decompressive therapy such as TIPS, or pharmacological treatment, seem to be ineffective for fundal varices associated with a gastrorenal shunt, and the obliteration of fundal varices in a safe manner could be justifiable. The authors proposed cyanoacrylate injection to be a more effective treatment than other therapeutic modalities for massive variceal bleeding [1]. We strongly agree that cyanoacrylate is undoubtedly the first-line treatment for bleeding from fundal varices, but the rebleeding rate is relatively high even if the varices can be eradicated initially [4] [5]. Further, the efficacy of cyanoacrylate in large fundal varices (greater than 12 mm) without active bleeding is controversial [6].

Balloon-occluded retrograde transvenous obliteration (B-RTO) is a recently devised interventional radiology technique for treating fundal varices associated with a gastrorenal shunt [7]. B-RTO is less invasive than TIPS, and it achieves excellent prevention of bleeding with few major complications, even in patients with poor liver function [7]. The main limitation on using B-RTO in an emergency setting seems to be the requirement for temporary control of bleeding with cyanoacrylate. Despite the lack of prospective randomized trials, we recommend elective B-RTO for the management of fundal varices associated with a gastrorenal shunt, at any portal pressure gradient value and for any variceal size, because of its simplicity and safety (Fig. [1]). Three-dimensional computed tomography [8] can accurately assess the presence of a gastrorenal shunt. A modified endoscopic injection technique [9] and new cyanoanoacrylate compounds [1] are needed.

Figure 1 Suggested algorithm for the management of isolated bleeding gastric fundal varices. FV, isolated gastric fundal varices; 3D-CT, three-dimensional computed tomography; PPG, portal pressure gradient; 12 ≤, less than or equal to 12 mm Hg; > 12, greater than 12 mm Hg; TIPS, transjugular intrahepatic portosystemic shunt; B-RTO, balloon-occluded retrograde transvenous obliteration.

References

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• 2 Watanabe K, Kimura K, Matsutani S. et al . Portal hemodynamics in patients with gastric varices: a study in 230 patients with esophageal and/or gastric varices using portal vein catheterization.  Gastroenterology. 1988;  95 434-440
• 3 Tripathi D, Therapondes G, Jackson E. et al . The role of the transjugular intrahepatic portosystemic stent shunt (TIPSS) in the management of bleeding gastric varices: clinical and hemodynamic correlations.  Gut. 2002;  51 270-274
• 4 Akahoshi T, Hashizume M, Shimabukuro R. et al . Long-term results of endoscopic Histoacryl injection sclerotherapy for gastric variceal bleeding: a 10-year experience.  Surgery. 2002;  131 S 176-181
• 5 Sarin S K, Jain A K, Jain M. et al . A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices.  Am J Gastroenterol. 2002;  97 1010-1015
• 6 Irisawa A, Obara K, Sato Y. et al . Adherence of cyanoacrylate which leaked from gastric varices to the left renal vein during endoscopic injection sclerotherapy: a histopathologic study.  Endoscopy. 2000;  32 804-806
• 7 Binmoeller K F, Borsatto R. Variceal bleeding and portal hypertension.  Endoscopy. 2000;  32 189-199
• 8 Matsumoto A, Kitamoto M, Imamura M. et al . Three-dimensional portography using multislice helical CT is clinically useful for management of gastric fundic varices.  AJR Am J Roentgenol. 2001;  176 899-905
• 9 Matsumoto A, Hamamoto N, Kayazawa M. Balloon endoscopic sclerotherapy, a novel treatment for high-risk gastric fundal varices: a pilot study.  Gastroenterology. 1999;  117 515-516