Gastric varices are dilated submucosal
vein
Veins are blood vessels in humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated b ...
s 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
Cirrhosis, also known as liver cirrhosis or hepatic cirrhosis, and end-stage liver disease, is the impaired liver function caused by the formation of scar tissue known as fibrosis due to damage caused by liver disease. Damage causes tissue rep ...
. 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
Acute pancreatitis (AP) is a sudden inflammation of the pancreas. Causes in order of frequency include: 1) a gallstone impacted in the common bile duct beyond the point where the pancreatic duct joins it; 2) heavy alcohol use; 3) systemic disea ...
,
pancreatic cancer
Pancreatic cancer arises when cell (biology), cells in the pancreas, a glandular organ behind the stomach, begin to multiply out of control and form a Neoplasm, mass. These cancerous cells have the malignant, ability to invade other parts of t ...
, or other abdominal tumours, as well as
hepatitis C
Hepatitis C is an infectious disease caused by the hepatitis C virus (HCV) that primarily affects the liver; it is a type of viral hepatitis. During the initial infection people often have mild or no symptoms. Occasionally a fever, dark urine, a ...
. Gastric varices and associated bleeding are a potential complication of
schistosomiasis
Schistosomiasis, also known as snail fever, bilharzia, and Katayama fever, is a disease caused by parasitic flatworms called schistosomes. The urinary tract or the intestines may be infected. Symptoms include abdominal pain, diarrhea, bloody s ...
resulting from portal hypertension.
Patients with bleeding gastric varices can present with bloody vomiting (
hematemesis
Hematemesis is the vomiting of blood. It is always an important sign. It can be confused with hemoptysis (coughing up blood) or epistaxis (nosebleed), which are more common. The source is generally the upper gastrointestinal tract, typically abo ...
), dark, tarry stools (
melena), or rectal bleeding. The bleeding may be brisk, and patients may soon develop
shock
Shock may refer to:
Common uses Collective noun
*Shock, a historic commercial term for a group of 60, see English numerals#Special names
* Stook, or shock of grain, stacked sheaves
Healthcare
* Shock (circulatory), circulatory medical emergen ...
. 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
Transjugular intrahepatic portosystemic shunt (TIPS or TIPSS) 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 is of ...
or TIPS. Treatment with intravenous
octreotide
Octreotide, sold under the brand name Sandostatin among others, is an octapeptide that mimics natural somatostatin pharmacologically, though it is a more potent inhibitor of growth hormone, glucagon, and insulin than the natural hormone. It was ...
is also useful to shunt blood flow away from the stomach's circulation. More aggressive treatment, including
splenectomy
A splenectomy is the surgical procedure that partially or completely removes the spleen. The spleen is an important organ in regard to immunological function due to its ability to efficiently destroy encapsulated bacteria. Therefore, removal of ...
(surgical removal of the
spleen
The spleen is an organ found in almost all vertebrates. Similar in structure to a large lymph node, it acts primarily as a blood filter. The word spleen comes . ) or
liver transplantation, may be required in some cases.
Signs and symptoms
![Fundusvarizen](https://upload.wikimedia.org/wikipedia/commons/6/6d/Fundusvarizen.jpg)
Gastric varices can present in two major ways. First, patients with
cirrhosis
Cirrhosis, also known as liver cirrhosis or hepatic cirrhosis, and end-stage liver disease, is the impaired liver function caused by the formation of scar tissue known as fibrosis due to damage caused by liver disease. Damage causes tissue rep ...
may be enrolled in screening
gastroscopy
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 ...
programs to detect
esophageal varices
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 ...
. 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
Upper gastrointestinal bleeding is gastrointestinal bleeding 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. D ...
. The symptoms can include
vomiting blood
Hematemesis is the vomiting of blood. It is always an important sign. It can be confused with hemoptysis (coughing up blood) or epistaxis (nosebleed), which are more common. The source is generally the upper gastrointestinal tract, typically abo ...
,
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.
Secondly, patients with
acute pancreatitis
Acute pancreatitis (AP) is a sudden inflammation of the pancreas. Causes in order of frequency include: 1) a gallstone impacted in the common bile duct beyond the point where the pancreatic duct joins it; 2) heavy alcohol use; 3) systemic disea ...
may present with gastric varices as a complication of a
blood clot
A thrombus (plural thrombi), colloquially called a blood clot, is the final product of the blood coagulation step in hemostasis. There are two components to a thrombus: aggregated platelets and red blood cells that form a plug, and a mesh of ...
in the
splenic vein. The splenic vein sits over the pancreas anatomically, and 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.
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.
In rare cases, gastric varices are caused by splenic vein occlusion as a result of the mass effect of slow-growing pancreatic
neuroendocrine tumors.
Diagnosis
Diagnosis of gastric varices is often made at the time of upper
endoscopy
An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...
.
Classification
The Sarin classification of gastric varices identifies four different anatomical types of gastric varices, which differ in terms of treatment modalities.
Treatment
Initial treatment of bleeding from gastric varices focuses on resuscitation, much as with
esophageal varices
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 ...
. This includes administration of fluids, blood products, and antibiotics.
Another treatment for gastric varices is injection of the varices with
cyanoacrylate, first described by German surgeon
Nib Soehendra and colleagues in 1986.
[ ] 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
Lipiodol, also known as ethiodized oil, is a poppyseed oil used by Injection (medicine), injection as a radio-opaque contrast agent that is used to outline structures in radiological investigations. It is used in Transcatheter arterial chemoemboli ...
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
The stomach is a muscular, hollow organ in the gastrointestinal tract of humans and many other animals, including several invertebrates. The stomach has a dilated structure and functions as a vital organ in the digestive system. The stomach i ...
.
Other techniques for refractory bleeding include:
*
Transjugular intrahepatic portosystemic shunts (TIPS)
* Balloon occluded retrograde transvenous obliteration techniques (BORTO)
* Coil-Assisted Retrograde Transvenous Obliteration (CARTO)
* Gastric variceal ligation, although this modality is falling out of favour
* Intra-gastric
balloon tamponade
Balloon tamponade usually refers to the use of balloons inserted into the esophagus, stomach or uterus, and inflated to alleviate or stop refractory bleeding.
Esophagus or stomach
When inserted into the esophagus or stomach, balloon catheters are ...
as a bridge to further therapy
** a caveat is that a larger balloon is required to occupy the
fundus of the stomach where gastric varices commonly occur
*
Liver transplantation
See also
*
Gastric antral vascular ectasia
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. T ...
References
External links
{{DEFAULTSORT:Gastric Varices
Stomach disorders
Diseases of veins, lymphatic vessels and lymph nodes