History

Fact Explanation
Vomiting blood [1] Gastric varices (GV) are dilated submucosal veins in the stomach, which can be a life-threatening cause of upper gastrointestinal hemorrhage.[1] Usually presented with massive bleeding [5] They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system.When these ruptures, it results in blood vomiting [1] Risk of rupture is lower for GV than esophegeal varicies (EV) , however GV rupture can be extremely severe and difficult to control, and is associated with higher mortality than EV bleeding [4] Risk factors for gastric variceal bleeding include variceal size (large, medium and small defined as > 10 mm, 5-10 mm and < 5 mm respectively), advanced Child’s grade of cirrhosis, presence of hepatocellular carcinoma [2]
History of cirrhosis [3] Regardless of the etiology of cirrhosis, the development of portal hypertension is nearly universal and results from an increased resistance to portal flow secondary to scarring, narrowing, and compression of the hepatic sinusoids. When the portal pressure exceeds a certain threshold, it results in the development of varices.Approximately 50 percent of patients with cirrhosis develop varices [3]
Passing black, tarry stools [1] Gastric varices are dilated submucosal veins in the stomach, which can be a life-threatening cause of upper gastrointestinal hemorrhage. When these ruptures, the blood can tract down the digestive tract and pass with stools.As this is bleeding from the upper gastrointestinal tract, the blood will get digested while going down the tract, so the stools will be black in colour [3]
Confusion, unconscious [2] Many patients with bleeding gastric varices present in shock due to the profound loss of blood [2]
Per rectal bleeding [3] Other portosystemic anastamoses can co exit with gastric varices (due to portal hypertension). One such condition is rectal varices due to portosystemic anastomosis between superior rectal veins and middle & inferior rectal veins.Per rectal bleeding occurs when the rectal varices rupture [3]
Distended veins in abdomen [3] Other portosystemic anastomosis can co exit with gastric varices (due to portal hypertension). Caput medusae - occurs due to portosystemic anastomosis between para umbilical veins and superficial epigastric veins [3]
Distended abdomen [3] Other symptoms and signs of portal hypertension may co exist with gastric varices.Portal hypertension plays an important role in the production of ascites by raising capillary hydrostatic pressure within the splanchnic bed [3]
References
  1. WILKINS T, KHAN N, NABH A, SCHADE RR. Diagnosis and management of upper gastrointestinal bleeding. Am Fam Physician [online] 2012 Mar 1, 85(5):469-76 [viewed 29 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22534226
  2. TRIANTAFYLLOU M, STANLEY AJ. Update on gastric varices World J Gastrointest Endosc [online] 2014 May 16, 6(5):168-175 [viewed 29 July 2014] Available from: doi:10.4253/wjge.v6.i5.168
  3. HEIDELBAUGH JJ, SHERBONDY M. Cirrhosis and chronic liver failure: part II. Complications and treatment. Am Fam Physician [online] 2006 Sep 1, 74(5):767-76 [viewed 29 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16970020
  4. FRANCO MC, GOMES GF, NAKAO FS, DE PAULO GA, FERRARI AP JR, LIBERA ED JR. Efficacy and safety of endoscopic prophylactic treatment with undiluted cyanoacrylate for gastric varices. World J Gastrointest Endosc [online] 2014 Jun 16, 6(6):254-9 [viewed 27 September 2014] Available from: doi:10.4253/wjge.v6.i6.254
  5. KERVANCIOGLU S, YILMAZ FG, GULSEN M, KERVANCIOGLU P, KERVANCIOGLU R. Massive upper gastrointestinal bleeding from an accessory splenic artery mimicking isolated gastric varices. Folia Morphol (Warsz) [online] 2013 Nov, 72(4):366-70 [viewed 27 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24402761

Examination

Fact Explanation
Signs of cirrhosis - ascites, jaundice, gynecomastia, loss of body hair, ankle odema etc. [1] Regardless of the etiology of cirrhosis, the development of portal hypertension is nearly universal and results from an increased resistance to portal flow secondary to scarring, narrowing, and compression of the hepatic sinusoids. When the portal pressure exceeds a certain threshold, it results in the development of varices [2]
Signs of shock - hypotension, tachycardia , cold peripheries [3] Many patients with bleeding gastric varices present in shock due to the profound loss of blood [3]
Pallor [2] Blood loss due to bleeding [2]
Ascites [2] Other symptoms and signs of portal hypertension may co exist with gastric varices. Portal hypertension plays an important role in the production of ascites by raising capillary hydrostatic pressure within the splanchnic bed [2]
Caput medusae [2] The appearance of distended and engorged paraumbilical veins, which are seen radiating from the umbilicus across the abdomen to join systemic veins.Occurs due to portosystemic anastamosis between para umbilical veins and superficial epigastric veins [2]
References
  1. STARR SP, RAINES D. Cirrhosis: diagnosis, management, and prevention. Am Fam Physician [online] 2011 Dec 15, 84(12):1353-9 [viewed 29 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22230269
  2. HEIDELBAUGH JJ, SHERBONDY M. Cirrhosis and chronic liver failure: part II. Complications and treatment. Am Fam Physician [online] 2006 Sep 1, 74(5):767-76 [viewed 29 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16970020
  3. TRIANTAFYLLOU M, STANLEY AJ. Update on gastric varices World J Gastrointest Endosc [online] 2014 May 16, 6(5):168-175 [viewed 29 July 2014] Available from: doi:10.4253/wjge.v6.i5.168

Differential Diagnoses

Fact Explanation
Hemoptysis [1] In the history there is absence of nausea and vomiting, history of lung disease Sputum examination-Frothy,bright red, pink Laboratory studies will show alkaline pH,Mixed with macrophages and neutrophils [1]
Non-variceal bleeding [2] History of peptic ulcer disease, use of non-steroidal anti-inflammatory drugs.History of dyspeptic symptoms. Endoscopy will show gastric ulcers [2]
References
  1. BIDWELL JL, PACHNER RW. Hemoptysis: diagnosis and management. Am Fam Physician [online] 2005 Oct 1, 72(7):1253-60 [viewed 29 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16225028
  2. WILKINS T, KHAN N, NABH A, SCHADE RR. Diagnosis and management of upper gastrointestinal bleeding. Am Fam Physician [online] 2012 Mar 1, 85(5):469-76 [viewed 29 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22534226

Investigations - for Diagnosis

Fact Explanation
Upper gastrointestinal endoscopy [1] Gastric varices are most commonly described using Sarin’s classification [2] This system uses their location in the stomach and their relationship to oesophageal varices. It divides them into gastro-oesophageal varices (GOVs) or isolated gastric varices (IGVs). GOVs are further sub-divided into GOV-1 which extend for 2-5 cm along the lesser curve of the stomach and GOV-2 which extend beyond the gastro-oesophageal junction into the fundus of the stomach [1]
Endoscopic ultra sound scan [3] gastric varices showed that blood flow velocity is higher in bleeding varices as compared to non bleeding varices, and the variceal wall is thinner in bleeding varices [3]
References
  1. TRIANTAFYLLOU M, STANLEY AJ. Update on gastric varices World J Gastrointest Endosc [online] 2014 May 16, 6(5):168-175 [viewed 29 July 2014] Available from: doi:10.4253/wjge.v6.i5.168
  2. GIROTRA M, RAGHAVAPURAM S, ABRAHAM RR, PAHWA M, PAHWA AR, REGO RF. Management of gastric variceal bleeding: Role of endoscopy and endoscopic ultrasound. World J Hepatol [online] 2014 Mar 27, 6(3):130-6 [viewed 27 September 2014] Available from: doi:10.4254/wjh.v6.i3.130
  3. SEICEAN A. Endoscopic ultrasound in the diagnosis and treatment of upper digestive bleeding: a useful tool. J Gastrointestin Liver Dis [online] 2013 Dec, 22(4):465-9 [viewed 27 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24369332

Investigations - Fitness for Management

Fact Explanation
Full blood count [1] Patient can have reduced hemoglobin levels due to bleeding [1] If the patient has cirrhosis, patient may have reduced platelet levels which can worsen the bleeding [2]
Liver function tests - Alanine transaminase , aspartate aminotransferase, Gamma-glutamyl transpeptidase, albumin, prothrombin time [2] Alanine transaminase , aspartate aminotransferase, Gamma-glutamyl transpeptidase will be elevated in liver diseases due to liver cell destruction.Albumin will be decreased in liver diseases due to reduced production.Prothrombin time will be increased due to reduced platelet production from the liver in liver diseases [2]
References
  1. TRIANTAFYLLOU M, STANLEY AJ. Update on gastric varices World J Gastrointest Endosc [online] 2014 May 16, 6(5):168-175 [viewed 29 July 2014] Available from: doi:10.4253/wjge.v6.i5.168
  2. STARR SP, RAINES D. Cirrhosis: diagnosis, management, and prevention. Am Fam Physician [online] 2011 Dec 15, 84(12):1353-9 [viewed 29 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22230269

Investigations - Followup

Fact Explanation
Upper gastrointestinal endoscopy [1] Patients with cirrhosis should be screened with upper endoscopy to rule out varices. If patients have no varices on initial endoscopy, the procedure should be repeated in three years [1]
Full blood count [2] Patients with variceal bleeding will have reduced hemoglobin levels due to bleeding [2]
References
  1. WILKINS T, KHAN N, NABH A, SCHADE RR. Diagnosis and management of upper gastrointestinal bleeding. Am Fam Physician [online] 2012 Mar 1, 85(5):469-76 [viewed 29 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22534226
  2. TRIANTAFYLLOU M, STANLEY AJ. Update on gastric varices World J Gastrointest Endosc [online] 2014 May 16, 6(5):168-175 [viewed 29 July 2014] Available from: doi:10.4253/wjge.v6.i5.168

Investigations - Screening/Staging

Fact Explanation
Upper gastrointestinal endoscopy [1] Gastric varices are most commonly described using Sarin’s classification. This system uses their location in the stomach and their relationship to oesophageal varices. It divides them into gastro-oesophageal varices (GOVs) or isolated gastric varices (IGVs). GOVs are further sub-divided into GOV-1 which extend for 2-5 cm along the lesser curve of the stomach and GOV-2 which extend beyond the gastro-oesophageal junction into the fundus of the stomach [1]
References
  1. TRIANTAFYLLOU M, STANLEY AJ. Update on gastric varices World J Gastrointest Endosc [online] 2014 May 16, 6(5):168-175 [viewed 29 July 2014] Available from: doi:10.4253/wjge.v6.i5.168

Management - General Measures

Fact Explanation
Primary prophylaxis - beta blockers [1] Reduce portal pressures both by decreasing cardiac output and by producing splanchnic vasoconstriction. Mortality was significantly lower in the group treated with cyanoacrylate (7%) compared with those given no-treatment (26%) but was not significant compared with the β-blockers group (17%). β-blockers [1]
Primary prophylaxis - cyanoacrylate injection [1] Used for gastric variceal obliteration.Mortality was significantly lower in the group treated with cyanoacrylate (7%) compared with those given no-treatment (26%) but was not significant compared with the β-blockers group (17%). β-blockers [1]
Screening for varices in cirrhotic patients [2] Patients with cirrhosis should be screened with upper endoscopy to rule out varices. If patients have no varices on initial endoscopy, the procedure should be repeated in three years [2]
References
  1. TRIANTAFYLLOU M, STANLEY AJ. Update on gastric varices World J Gastrointest Endosc [online] 2014 May 16, 6(5):168-175 [viewed 29 July 2014] Available from: doi:10.4253/wjge.v6.i5.168
  2. WILKINS T, KHAN N, NABH A, SCHADE RR. Diagnosis and management of upper gastrointestinal bleeding. Am Fam Physician [online] 2012 Mar 1, 85(5):469-76 [viewed 29 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22534226

Management - Specific Treatments

Fact Explanation
Treatment of acute bleeding - Volume restitution [1] Volume restitution should be commenced immediately to maintain haemodynamic stability with blood transfusion as necessary aiming for target haemoglobin of 7-8 g/dL.Intra venous fluid is required to maintain the hemodynamic stability [1]
Treatment of acute bleeding - Vasoactive drugs [1] Vasoactive drugs should be commenced as soon as possible if variceal bleeding is suspected. Pharmacologic treatment (including terlipressin, somatostatin or octreotide) for variceal bleeding in cirrhosis are beneficial as first-line treatment [1]
Treatment of acute bleeding - Prophylactic antibiotics [1] Prophylactic antibiotics should be administrated early to patients with suspected or confirmed variceal bleeding as this has been shown to reduce mortality and risk of infection.Oral quinolones are often recommended, however the antibiotic choice is often guided by local microbiological advice [1]
Endoscopic therapies - Variceal band ligation [1] Used in treatment of acute bleeding. Variceal band ligation is the gold standard for the endoscopic management of oesophageal variceal haemorrhage, but its role in gastric variceal bleeding is less clear. In a prospective randomized trial, the efficacy of band ligation to arrest active gastric variceal bleeding in cirrhotic patients was comparable to cyanoacrylate injection, but the rebleeding rate was higher in the banding group. No difference in complications was found between the groups. Variceal banding is generally only used as secondary prophylaxis ( prevention of rebleed ) for GOV-1 varices, but not for other types of gastric varices. [1]
Endoscopic therapies - Sclerotherapy [1] Used in treatment of acute bleeding. Pure alcohol is injected into the vessels, which makes them shrink.A study of gastric variceal sclerotherapy with pure alcohol for acute gastric variceal bleeding reported a haemostatic rate of 66%.Complications associated with the procedure include fever, retrosternal and abdominal pain, dysphagia, rebleeding and ulceration [1]
Endoscopic therapies - Tissue glues [2] Used in treatment of acute bleeding. Cyanoacrylate is a monomer that undergoes rapid polymerization in presence of ionic substances including blood or tissue fluids. Tissue adhesives include histoacryl (N-butyl-cyanoacrylate) and bucrylate (isobutyl -2-cyanoacrylate) and both have been used with success for gastric varices obliteration. Current evidence of the use of tissue adhesives for gastric variceal bleeding suggests haemostasis control in > 90%. A randomized trial of cyanoacrylate injection vs TIPS for gastric variceal bleeding showed similar survival and complication rates in both groups, but TIPS was more effective in preventing rebleeding (11% vs 38%) Also used in prevntion of rebleed.Cyanoacrylate injection is significantly more effective than β-blocker treatment for the prevention of rebleeding from gastric varices [1]
Endoscopic therapies - Thrombin [1] Used in treatment of acute bleeding. Thrombin affects haemostasis by converting fibrinogen to fibrin clot and also influences platelet aggregation. Thrombin is a promising therapy for bleeding gastric varices but to date no randomized data on its use are available and longer term follow-up is required, therefore more studies are required. Thrombin seems to be an effective and safe treatment to reduce gastric variceal rebleeding and repeated injections to achieve eradication may not be necessary [1]
Intra-gastric balloon [1] Used in treatment of acute bleeding. Temporary use of an intra-gastric balloon such as the Sengstaken-Blackmore tube to tamponade fundal varices may be helpful if bleeding continues despite pharmacologic and endoscopic therapies. This is often used as a bridge to more definitive therapy including placement of a transjugular intrahepatic portosystemic shunt [1]
Radiologic therapies - Transjugular intrahepatic portosystemic shunts ( TIPS ) [5] Used in treatment of acute bleeding. 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. An American retrospective comparative study compared TIPS with cyanoacrylate injection for gastric variceal bleeding. No differences were found in survival or rebleeding, but the group treated with TIPS had an increased morbidity requiring prolonged hospitalization because of encephalopathy. TIPS can also be used if bleeding from gastric varices is not controlled with N-butyl-cyanoacrylate injection, however the portal vein must be patent and careful patient selection is required to minimize risks of encephalopathy. TIPS insertion appears effective for the prevention of gastric variceal rebleeding, although it is more invasive than endoscopic methods, has associated risks of encephalopathy and is not always available [1]
Radiologic therapies - Balloon-occluded retrograde transvenous obliteration (BRTO) [3] Used in treatment of acute bleeding. The right femoral or internal jugular vein is punctured and a balloon catheter is inserted into the left renal vein. After balloon inflation, venography is performed to identify gastric varices, gastrorenal shunts and collateral veins. The veins draining gastric varices are embolised with microcoils and a sclerosant agent is injected until all varices are obliterated. The haemostasis and rebleeding rates of cyanoacrylate were 100% and 71.4% respectively compared with 76.9% and 15.4% respectively for BRTO. Can also be used to prevent releeding. [1] BRTO is not suitable for gastric varices that lack a main draining vein, as they cannot be catheterized. [4]
Prevention of rebleed (secondary prophylaxis) - Non selective β-blockers [1] These medications reduce portal pressures both by decreasing cardiac output and by producing splanchnic vasoconstriction. The cumulative two year survival rates in the cyanoacrylate and beta blocker groups were 90% and 52% respectively, with the difference linked to higher rebleeding in the β-blocker group [1]
References
  1. TRIANTAFYLLOU M, STANLEY AJ. Update on gastric varices World J Gastrointest Endosc [online] 2014 May 16, 6(5):168-175 [viewed 29 July 2014] Available from: doi:10.4253/wjge.v6.i5.168
  2. TOAPANTA-YANCHAPAXI L, CHAVEZ-TAPIA N, TéLLEZ-ÁVILA F. Cyanoacrylate spray as treatment in difficult-to-manage gastrointestinal bleeding. World J Gastrointest Endosc [online] 2014 Sep 16, 6(9):448-52 [viewed 26 September 2014] Available from: doi:10.4253/wjge.v6.i9.448
  3. BORGHEI P, KIM SK, ZUCKERMAN DA. Balloon occlusion retrograde transvenous obliteration of gastric varices in two non-cirrhotic patients with portal vein thrombosis. Korean J Radiol [online] 2014 Jan-Feb, 15(1):108-13 [viewed 27 September 2014] Available from: doi:10.3348/kjr.2014.15.1.108
  4. UCHIYAMA F, MURATA S, ONOZAWA S, NAKAZAWA K, SUGIHARA F, YASUI D, NARAHARA Y, UCHIDA E, AMANO Y, KUMITA S. Management of gastric varices unsuccessfully treated by balloon-occluded retrograde transvenous obliteration: long-term follow-up and outcomes. ScientificWorldJournal [online] 2013:498535 [viewed 27 September 2014] Available from: doi:10.1155/2013/498535
  5. YANG L, YUAN LJ, DONG R, YIN JK, WANG Q, LI T, LI JB, DU XL, LU JG. Two surgical procedures for esophagogastric variceal bleeding in patients with portal hypertension. World J Gastroenterol [online] 2013 Dec 28, 19(48):9418-24 [viewed 27 September 2014] Available from: doi:10.3748/wjg.v19.i48.9418