Gastric Varices

What is Gastric Varices?

Gastric varices are enlarged veins found under the lining of the stomach, which usually occur due to high blood pressure in the liver (also known as portal hypertension) caused by various conditions, with or without liver cirrhosis. Even though these veins are not as common as esophageal varices, being observed in about 20% of patients with cirrhosis, they have a higher tendency to bleed heavily and may often result in poor health outcomes.

Gastric varices are categorized based on their location in the stomach into two types: gastroesophageal varices (GOV) and isolated gastric varices (IGV). The naming system most typically used to classify these veins is the Sarin classification.

Gastroesophageal varices are expansions of the esophageal varices (veins in the esophagus). They’re classified as GOV type 1 (GOV1) when they extend below the gastroesophageal junction along the lesser curvature, and GOV type 2 (GOV2) when they stretch into the fundus (upper part) of the stomach. On the other hand, Isolated gastric varices (IGV) located in the fundus of the stomach are referred to as IGV type 1 (IGV1) or commonly called fundal varices. IGV type 2 (IGV2) are broadened varices located anywhere in the stomach aside from the aforementioned areas. Among all gastric varices, GOV1 is the most common, accounting for almost 75%, followed by GOV2 with 21%, IGV1 with less than 2%, and IGV2, which includes 4%.

What Causes Gastric Varices?

Gastric varices, or abnormal veins in the stomach, are often seen in patients with liver disease caused by a condition called portal hypertension. However, these unusual veins can also appear in patients who have portal hypertension for reasons other than liver disease. It’s important to understand that the causes, development, and ways of handling these two scenarios are different.

So what causes portal hypertension related to liver disease? There are several possibilities:

* Drinking too much alcohol
* Certain viruses that cause liver inflammation (Hepatitis B or C)
* Fatty liver disease not related to alcohol use
* An autoimmune condition where the body attacks the liver
* A disease causing inflammation and damage to the bile ducts
* Hardening and scarring of the bile ducts
* Genetic conditions affecting iron levels (Hereditary hemochromatosis)
* Wilson’s disease, which causes copper to build up in the liver
* Alpha-1 antitrypsin deficiency, a disorder that may cause lung disease and liver disease

On the other hand, portal hypertension not related to liver disease can result from:

* Blockages outside of the liver in the portal vein (Extrahepatic portal venous obstruction)
* Blood clots in the portal vein or the splenic vein
* Conditions leading to an enlarged spleen due to chronic inflammation of the pancreas, pancreatic fluid collections, or pancreatic growths
* Conditions causing abnormal enlargement of blood cells (macrocytosis), or abnormal proteins in our organs (amyloidosis)
* A genetic condition leading to development of fibrous tissue in the liver (congenital hepatic fibrosis)
* Parasitic infections such as Schistosomiasis
* Accumulation of fibrous tissue in the portal area of the liver not related to cirrhosis (Noncirrhotic portal fibrosis)
* Certain medications
* Obstructions in the veins draining blood from the liver (Hepatic venous outflow tract obstruction)
* A condition leading to formation of granules in body tissues (sarcoidosis)
* Obstruction of the inferior vena cava, a large vein that carries de-oxygenated blood from the lower body to the heart
* A condition where the pericardium, a thin sac-like membrane surrounding the heart, becomes hard and rigid (constrictive pericarditis)
* Severe failure of the right side of the heart

Risk Factors and Frequency for Gastric Varices

While accurate numbers are unknown, gastric varices are estimated to affect about 15 to 20% of patients with cirrhotic and non-cirrhotic hypertension, according to studies of over 500 patients at two centers. With the development of endoscopic ultrasound, rates could be even higher, between 55% to 78%. Additionally, if a patient also has underlying portal hypertension, the risk of bleeding from gastric varices can range from 10% to 30%.

Signs and Symptoms of Gastric Varices

When a person is newly diagnosed with cirrhosis and the cause isn’t known, doctors need to find out about any history of alcohol or drug use, as well as whether liver disorders run in the family. People already diagnosed with advanced cirrhosis need to report any past or current instances of variceal bleeding (which includes symptoms like vomiting blood, black stools, bloody stools), ascites (such as swelling, discomfort, fullness, leg swelling, trouble breathing, difficulty lying flat), or hepatic encephalopathy (symptoms such as becoming confused or excessively sleepy). For people without cirrhosis but with unexpected findings of gastric varices, it’s important to gather any personal or family history of blood-clotting disorders as well as a history of pancreatic disorders.

All patients should have their vital signs checked routinely, this includes heart rate, blood pressure, respiratory rate, and oxygen levels. A specific examination should be done focusing on signs related to cirrhosis and increased blood pressure in the liver’s blood vessels (portal hypertension). The signs to look for are:

Yellow eyes (scleral icterus)
Raised neck veins (elevated jugular venous pulse) due to the heart failing on the right side
Fluid in the chest cavity (pleural effusion or hepatohydrothorax)
Ascites, which is indicated by a distended abdomen, full flanks, a fluid thrill, a puddle sign, shifting dullness, or abdominal tenderness
An enlarged spleen
Blood vessels visible around the belly button (caput-medusae)
Spider-like blood vessels on the skin
Swelling (edema), yellow skin (icteric skin), a flapping tremor (asterixis), red palms (palmar erythema), finger contractures (Dupuytren contracture), or white discoloration of the nails (Terry nails)
Shrunken testicles (testicular atrophy) or scrotal edema
Obvious or subtle signs of brain dysfunction due to liver disease (overt and covert encephalopathy), along with asterixis
Enlarged breast tissue in men (gynecomastia) or a sweet, musty breath odor (fetor hepaticus)

Gastric varices, unlike esophageal varices, don’t commonly cause acute bleeding and are usually found during routine screening for varices in people with portal hypertension. Major risk factors for bleeding include the severity of the liver problem, the location and size of the varices, and the presence of bleeding signs. Acute gastric variceal bleeding can be severe and life-threatening, making patients especially sick at presentation. The GOV2 subtype of gastric varices tends to bleed more often than GOV1 and is associated with a worse prognosis. Patients with segmental portal hypertension due to splenic vein thrombosis in pancreatic disorders often find out incidentally that they have gastric varices from imaging studies.

Testing for Gastric Varices

When a patient is newly diagnosed with cirrhosis, comprehensive laboratory tests are necessary to determine the cause of the condition. If the patient exhibits signs of worsening cirrhosis, such as abrupt variceal bleeding – which is severe bleeding from enlarged veins, initial blood tests, liver and kidney function tests, clotting profile, and arterial blood gas analysis, which tests the amount of oxygen and carbon dioxide in the blood, should be carried out.

An esophagogastroduodenoscopy (EGD) – a procedure where a small tube with a camera is used to view the esophagus, stomach, and the first part of the small intestine, should be performed. This is done to assess and categorize gastric varices – swollen veins in the stomach wall that can burst and bleed, in patients with advanced cirrhosis. This examination is also crucial if gastric varices are inadvertently discovered in scans on patients without cirrhosis.

Another helpful tool is the Endoscopic ultrasound (EUS) – an imaging test that uses sound waves to create pictures of the digestive tract including the esophagus, stomach and the starting part of the small intestine. This examination helps better define the gastric varices, and has increasingly been used in the management of this condition.

Non-invasive diagnostic methods can be used to measure the severity of liver fibrosis – which is the thickening and scaring of tissue. For instance, the transient elastography, a kind of ultrasound that measures the stiffness of your liver. This is helpful for patients that could be developing clinically significant hypertension in the portal vein, which is a large vein that carries blood from your intestines and spleen to your liver.

Invasive diagnostic methods, like the Hepatic Venous Pressure Gradient (HVPG) measurement, can be used to diagnose severe vein hypertension and to estimate their risk of severe bleeding from varices. Liver ultrasound, CT or MRI scans can help confirm cirrhosis and rule out liver cancer.

Tests like the Hepatic Doppler sonography – an ultrasound that looks at the blood flow in the vessels of your liver, CT or MRI angiography, venous phase celiac arteriography – a type of X-ray that looks at the blood vessels in your belly, can check the openness of the portal and splenic veins and rule out blood clotting.

A liver biopsy, where a small piece of the liver is removed and examined under a microscope, may be considered to evaluate the severity of liver scarring and to determine the cause in patients with cirrhosis, especially those whose laboratory tests do not reveal the cause.

Treatment Options for Gastric Varices

While the best way to manage gastric varices may still be unknown due to a lack of large-scale, high-quality clinical trials, the preferred treatment for a type of gastric varices called GOV1 is generally agreed upon and is similar to that of esophageal varices. For other types of gastric varices (GOV2/IGV1), the treatment approach depends on the severity of the presentation and falls into three categories: primary prophylaxis (prevention), management of acute (sudden or severe) variceal bleeding, and secondary prophylaxis (prevention of recurrence).

Primary prophylaxis could include using beta-blockers as a long-term preventative treatment for high blood pressure in the portal vein, the vein that carries blood from the digestive organs to the liver. These medications include propranolol or nadolol and they might help to prevent an initial bleed from GOV2 or IGV1 varices.

When a patient presents with acute gastric variceal bleeding, they are usually admitted to the Intensive Care Unit (ICU) for initial resuscitation. This typically includes a transfusion of packed red blood cells, correction of any clotting disorders or low platelet counts and the administration of broad-spectrum antibiotics. The use of blood vessel constricting agents such as octreotide, vasopressin, terlipressin, and somatostatin in managing gastric variceal bleeding is not fully understood, but they might be used due to their safety and potential benefits. An urgent upper endoscopy is usually performed for diagnosis and treatment.

For endoscopic therapies, tissue adhesives like cyanoacrylate-based adhesives or thrombin and endoscopic variceal ligation (a surgical procedure to tie-off enlarged veins) can be used. Endoscopic injection sclerotherapy, which involves the injection of hardening agents into the varices or enlarged veins, is not generally recommended due to increased complications and rebleeding rates.

A type of synthetic glue called cyanoacrylate (CYA) glue might be used during endoscopy. It solidifies quickly when exposed to water or blood and causes the blood in the veins to clot, leading to the halt of bleeding. A study revealed that patients treated with cyanoacrylate injection had higher active bleeding control rate, and lower rebleeding and gastric varices recurrence rates compared to patients who were treated with endoscopic variceal ligation.

If acute gastric variceal bleeding cannot be controlled with endoscopic intervention, two other procedures, transjugular intrahepatic portosystemic shunt (TIPS) or Balloon occluded retrograde transvenous obliteration (BRTO), may be used. TIPS is a procedure that involves creating a connection between the liver and portal veins to reduce portal pressure, while BRTO involves injecting a sclerosing agent into the gastric varix to cause it to harden and stop bleeding. Another method to control gastric variceal bleeding is the use of balloon tamponade, which is the inflation of a balloon inside the esophagus to compress the varices and stop the bleeding. This is usually considered a temporary solution to control severe bleeding before more definitive treatments can be arranged.

In the case of extreme scenarios where treatments mentioned above fail, a surgical approach might be required. Procedures like splenectomy (removal of the spleen) or embolization of the splenic artery (a procedure to block the artery that supplies blood to the spleen) could be considered, especially for patients whose condition is due to sinistral or left-sided portal hypertension caused by the clotting of the splenic vein.

For secondary prophylaxis, nonselective beta-blockers combined with endoscopy evaluation therapy are usually recommended as the first-line therapy to prevent rebleeding in patients recovering from GOV1 hemorrhage. Patients recovering from gastric variceal hemorrhage secondary to GOV2 or IGV1 varices are usually treated with TIPS or BRTO. If these procedures cannot be performed for technical reasons, secondary prophylaxis options include EUS guided cyanoacrylate glue injection, or EUS guided coil embolization.

When diagnosing the cause of gastric varices, or swollen veins in the stomach that may cause vomiting of blood, doctors look at a number of potential conditions that can cause upper digestive track bleeding. These include:

Peptic ulcer disease (PUD)
Esophageal varices
Acute gastric erosions
Ulcers in the lining of the stomach
Malignant stomach ulcers
Dieulafoy’s lesion, a condition where an artery in the stomach wall bleeds
Mallory-Weiss tear, a tear in the lining of the esophagus or stomach
PHG, a condition where high blood pressure in the liver affects the stomach lining
GAVE, a condition where the lining of the stomach bleeds

However, if there’s no bleeding and abnormalities are found during an upper endoscopy, then doctors look at other potential causes that might include:

Epithelial lesions that can take different forms like lipomas, duplication cysts, or pancreatic rests
Carcinoid tumor
Lymphangiomas, benign tumors of the lymph vessels
Stomach lymphoma, a type of cancer that starts in immune cells
GIST, a type of tumor that develops in the digestive tract
Inflammatory gastric polyp, a growth in the lining of the stomach

What to expect with Gastric Varices

Gastric varices and portal hypertension are conditions related to blood vessels in the stomach and liver, respectively. Even though acute bleeding from gastric varices is less common than esophageal (or gullet) variceal bleeding, it tends to be more severe when it does occur. This increases the risk of death more compared to esophageal variceal bleeding.

The overall outlook for these conditions depends greatly on the severity of the base illness. Models like the Child-Pugh score and the Model for End-Stage Liver Disease (MELD) score are often used to determine how severe the underlying liver disease is. These models also help to predict the risk of death in patients with these conditions.

Possible Complications When Diagnosed with Gastric Varices

Spontaneous rupture of gastric varices, which are abnormally swollen veins in the stomach, can lead to serious outcomes. These may include:

Inhaling food, stomach acid, or saliva into the lungs (aspiration)
Severe loss of blood leading to low red blood cell levels (acute blood loss anemia)
Sudden drop in blood pressure requiring medical attention (hemorrhagic shock)
Failure of two or more organs in your body (multiorgan failure)
Higher risk of bacterial infections
Death

Frequently asked questions

Gastric varices are enlarged veins found under the lining of the stomach, which usually occur due to high blood pressure in the liver caused by various conditions, with or without liver cirrhosis. They have a higher tendency to bleed heavily and may often result in poor health outcomes.

Gastric varices are estimated to affect about 15 to 20% of patients with cirrhotic and non-cirrhotic hypertension, according to studies of over 500 patients at two centers.

The signs and symptoms of Gastric Varices include: - Vomiting blood - Black stools - Bloody stools - Swelling, discomfort, fullness, leg swelling, trouble breathing, difficulty lying flat (indicating ascites) - Confusion or excessive sleepiness (indicating hepatic encephalopathy) - Yellow eyes (scleral icterus) - Raised neck veins (elevated jugular venous pulse) due to right-sided heart failure - Fluid in the chest cavity (pleural effusion or hepatohydrothorax) - Distended abdomen, full flanks, fluid thrill, puddle sign, shifting dullness, or abdominal tenderness (indicating ascites) - Enlarged spleen - Blood vessels visible around the belly button (caput-medusae) - Spider-like blood vessels on the skin - Swelling (edema), yellow skin (icteric skin), flapping tremor (asterixis), red palms (palmar erythema), finger contractures (Dupuytren contracture), or white discoloration of the nails (Terry nails) - Shrunken testicles (testicular atrophy) or scrotal edema - Obvious or subtle signs of brain dysfunction due to liver disease (overt and covert encephalopathy), along with asterixis - Enlarged breast tissue in men (gynecomastia) or a sweet, musty breath odor (fetor hepaticus) It's important to note that gastric varices don't commonly cause acute bleeding and are usually found during routine screening for varices in people with portal hypertension. The severity of the liver problem, the location and size of the varices, and the presence of bleeding signs are major risk factors for bleeding. The GOV2 subtype of gastric varices tends to bleed more often than GOV1 and is associated with a worse prognosis.

Gastric varices can be caused by portal hypertension, which can be related to liver disease or other conditions such as blockages in the portal vein, blood clots, chronic inflammation of the pancreas, genetic conditions, parasitic infections, certain medications, and other factors.

The other conditions that a doctor needs to rule out when diagnosing Gastric Varices include: - Peptic ulcer disease (PUD) - Esophageal varices - Acute gastric erosions - Ulcers in the lining of the stomach - Malignant stomach ulcers - Dieulafoy's lesion, a condition where an artery in the stomach wall bleeds - Mallory-Weiss tear, a tear in the lining of the esophagus or stomach - PHG, a condition where high blood pressure in the liver affects the stomach lining - GAVE, a condition where the lining of the stomach bleeds - Epithelial lesions that can take different forms like lipomas, duplication cysts, or pancreatic rests - Carcinoid tumor - Lymphangiomas, benign tumors of the lymph vessels - Stomach lymphoma, a type of cancer that starts in immune cells - GIST, a type of tumor that develops in the digestive tract - Inflammatory gastric polyp, a growth in the lining of the stomach

The types of tests needed for Gastric Varices include: 1. Initial blood tests, liver and kidney function tests, clotting profile, and arterial blood gas analysis. 2. Esophagogastroduodenoscopy (EGD) to assess and categorize gastric varices. 3. Endoscopic ultrasound (EUS) to better define the gastric varices. 4. Non-invasive diagnostic methods like transient elastography to measure the severity of liver fibrosis. 5. Invasive diagnostic methods like Hepatic Venous Pressure Gradient (HVPG) measurement to diagnose severe vein hypertension. 6. Liver ultrasound, CT or MRI scans to confirm cirrhosis and rule out liver cancer. 7. Hepatic Doppler sonography, CT or MRI angiography, and venous phase celiac arteriography to check the openness of the portal and splenic veins and rule out blood clotting. 8. Liver biopsy to evaluate the severity of liver scarring and determine the cause in patients with cirrhosis.

The treatment approach for gastric varices depends on the type and severity of the presentation. For a type of gastric varices called GOV1, the preferred treatment is similar to that of esophageal varices. For other types of gastric varices (GOV2/IGV1), the treatment approach falls into three categories: primary prophylaxis (prevention), management of acute variceal bleeding, and secondary prophylaxis (prevention of recurrence). Primary prophylaxis may involve using beta-blockers to prevent an initial bleed. Acute variceal bleeding is managed with resuscitation, transfusion, antibiotics, and endoscopic therapies such as tissue adhesives or variceal ligation. If endoscopic intervention fails, procedures like TIPS, BRTO, or balloon tamponade may be used. In extreme cases, surgical approaches like splenectomy or embolization of the splenic artery may be considered. Secondary prophylaxis options include nonselective beta-blockers combined with endoscopy evaluation therapy or TIPS/BRTO for certain types of varices.

The side effects when treating Gastric Varices may include: - Inhaling food, stomach acid, or saliva into the lungs (aspiration) - Severe loss of blood leading to low red blood cell levels (acute blood loss anemia) - Sudden drop in blood pressure requiring medical attention (hemorrhagic shock) - Failure of two or more organs in your body (multiorgan failure) - Higher risk of bacterial infections - Death

The prognosis for Gastric Varices depends on the severity of the underlying liver disease. Models like the Child-Pugh score and the Model for End-Stage Liver Disease (MELD) score are used to determine the severity of the liver disease and predict the risk of death in patients with Gastric Varices. Acute bleeding from Gastric Varices is less common than esophageal variceal bleeding, but when it does occur, it tends to be more severe and increases the risk of death compared to esophageal variceal bleeding.

A gastroenterologist.