Gastric varices
Encyclopedia
Gastric varices are dilated submucosal vein
s in the stomach
, which can be a life-threatening cause of upper gastrointestinal hemorrhage. 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
. Gastric varices may also be found in patients with thrombosis of the splenic vein
, into which the short gastric veins which drain the fundus
of the stomach flow. The latter may be a complication of acute pancreatitis
, pancreatic cancer
, or other abdominal tumours. Patients with bleeding gastric varices can present with bloody vomiting (hematemesis
), dark, tarry stools (melena
), or frank rectal bleeding. The bleeding may be brisk, and patients may soon develop shock. 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
or TIPS. Treatment with intravenous octreotide
is also useful to shunt blood flow away from the stomach's circulation. More aggressive treatment including splenectomy
(or surgical removal of the spleen
) or liver transplantation
may be required in some cases.
may be enrolled in screening gastroscopy programs to detect esophageal varices
. These evaluations may detect gastric varices that are asymptomatic. When gastric varices are symptomatic, however, they usually present acutely and dramatically with upper GI hemorrhage. The symptoms can include hematemesis
, or vomiting
blood; melena
, passing black, tarry stools; or passing maroon stools or frank blood in the stools. Many patients with bleeding gastric varices present in shock due to the profound loss of blood.
Secondly, patients with acute pancreatitis
may present with gastric varices as a complication of thrombosis of the splenic vein
. The splenic vein sits over the pancreas anatomically and inflammation or cancers of the pancreas may result in thrombosis, or clotting of 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 anemia
and often thrombocytopenia
(a low platelet
count). If cirrhosis is present, there may be coagulopathy
manifested by a prolonged INR; both of these may worsen the hemorrhage from gastric varices.
In very rare cases, gastric varices are caused by splenic vein occlusion as a result of the mass effect of slow-growing pancreatic neuroendocrine tumors.
Diagnosis of gastric varices is often made at the time of upper endoscopy
.
The Sarin classification of gastric varices identifies four different anatomical types of gastric varices, which differ in terms of treatment modalities.
. This includes administration of fluids, blood products, and antibiotics.
The results from the only two randomized trials comparing band ligation vs cyanocarylate 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
to prevent polymerization in the endoscopy delivery optics, and to show on radiographic imaging. GVO is usually performed is specialized therapeutic endoscopy centers. Complications include sepsis, embolization of glue, and obstruction from polymerization in the lumen of the stomach
.
Other techniques for refractory bleeding include:
Vein
In the circulatory system, veins are blood vessels 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 blood to the heart...
s in the stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
, which can be a life-threatening cause of upper gastrointestinal hemorrhage. They are most commonly found in patients with portal hypertension
Portal hypertension
In medicine, portal hypertension is hypertension in the portal vein and its tributaries.It is often defined as a portal pressure gradient of 10 mmHg or greater.-Causes:Causes can be divided into prehepatic, intrahepatic, and posthepatic...
, or elevated pressure in the portal vein system, which may be a complication of cirrhosis
Cirrhosis
Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules , leading to loss of liver function...
. Gastric varices may also be found in patients with thrombosis of the splenic vein
Splenic vein
In anatomy, the splenic vein is the blood vessel that drains blood from the spleen.It joins with the superior mesenteric vein, to form the hepatic portal vein and follows a course superior to the pancreas, alongside of the similarly named artery, the splenic artery.It collects branches from the...
, into which the short gastric veins which drain the fundus
Fundus (stomach)
The fundus of the stomach is the left portion of the stomach's body, and is marked off from the remainder of the body by a plane passing horizontally through the cardiac orifice....
of the stomach flow. The latter may be a complication of acute pancreatitis
Acute pancreatitis
Acute pancreatitis or acute pancreatic necrosis is a sudden inflammation of the pancreas. It can have severe complications and high mortality despite treatment...
, pancreatic cancer
Pancreatic cancer
Pancreatic cancer refers to a malignant neoplasm of the pancreas. The most common type of pancreatic cancer, accounting for 95% of these tumors is adenocarcinoma, which arises within the exocrine component of the pancreas. A minority arises from the islet cells and is classified as a...
, or other abdominal tumours. Patients with bleeding gastric varices can present with bloody vomiting (hematemesis
Hematemesis
Hematemesis or haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract. Patients can easily confuse it with hemoptysis , although the latter is more common.-Signs:...
), dark, tarry stools (melena
Melena
In medicine, melena or melaena refers to the black, "tarry" feces that are associated with gastrointestinal hemorrhage. The black color is caused by oxidation of the iron in hemoglobin during its passage through the ileum and colon.-Melena vs...
), or frank rectal bleeding. The bleeding may be brisk, and patients may soon develop shock. Treatment of gastric varices can include injection of the varices with cyanoacrylate
Cyanoacrylate
Cyanoacrylate is the generic name for cyanoacrylate based fast-acting adhesives such as methyl 2-cyanoacrylate, ethyl-2-cyanoacrylate , and n-butyl cyanoacrylate...
glue, or a radiological procedure to decrease the pressure in the portal vein, termed transjugular intrahepatic portosystemic shunt
Transjugular intrahepatic portosystemic shunt
A Transjugular Intrahepatic Portosystemic Shunt is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein...
or TIPS. Treatment with intravenous octreotide
Octreotide
Octreotide 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...
is also useful to shunt blood flow away from the stomach's circulation. More aggressive treatment including splenectomy
Splenectomy
A splenectomy is a surgical procedure that partially or completely removes the spleen.-Indications:The spleen, similar in structure to a large lymph node, acts as a blood filter. Current knowledge of its purpose includes the removal of old red blood cells and platelets, and the detection and fight...
(or surgical removal of the spleen
Spleen
The spleen is an organ found in virtually all vertebrate animals with important roles in regard to red blood cells and the immune system. In humans, it is located in the left upper quadrant of the abdomen. It removes old red blood cells and holds a reserve of blood in case of hemorrhagic shock...
) or liver transplantation
Liver transplantation
Liver transplantation or hepatic transplantation is the replacement of a diseased liver with a healthy liver allograft. The most commonly used technique is orthotopic transplantation, in which the native liver is removed and replaced by the donor organ in the same anatomic location as the original...
may be required in some cases.
Clinical presentation
Gastric varices can present in two major ways. First, patients with cirrhosisCirrhosis
Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules , leading to loss of liver function...
may be enrolled in screening gastroscopy programs to detect esophageal varices
Esophageal varices
In medicine , esophageal varices are extremely dilated sub-mucosal veins in the lower esophagus...
. These evaluations may detect gastric varices that are asymptomatic. When gastric varices are symptomatic, however, they usually present acutely and dramatically with upper GI hemorrhage. The symptoms can include hematemesis
Hematemesis
Hematemesis or haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract. Patients can easily confuse it with hemoptysis , although the latter is more common.-Signs:...
, or vomiting
Vomiting
Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...
blood; melena
Melena
In medicine, melena or melaena refers to the black, "tarry" feces that are associated with gastrointestinal hemorrhage. The black color is caused by oxidation of the iron in hemoglobin during its passage through the ileum and colon.-Melena vs...
, passing black, tarry stools; or passing maroon stools or frank blood in the stools. Many patients with bleeding gastric varices present in shock due to the profound loss of blood.
Secondly, patients with acute pancreatitis
Acute pancreatitis
Acute pancreatitis or acute pancreatic necrosis is a sudden inflammation of the pancreas. It can have severe complications and high mortality despite treatment...
may present with gastric varices as a complication of thrombosis of the splenic vein
Splenic vein
In anatomy, the splenic vein is the blood vessel that drains blood from the spleen.It joins with the superior mesenteric vein, to form the hepatic portal vein and follows a course superior to the pancreas, alongside of the similarly named artery, the splenic artery.It collects branches from the...
. The splenic vein sits over the pancreas anatomically and inflammation or cancers of the pancreas may result in thrombosis, or clotting of the splenic vein. As the short gastric veins of the fundus
Fundus (stomach)
The fundus of the stomach is the left portion of the stomach's body, and is marked off from the remainder of the body by a plane passing horizontally through the cardiac orifice....
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 anemia
Anemia
Anemia is a decrease in number of red blood cells or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin...
and often thrombocytopenia
Thrombocytopenia
Thrombocytopenia is a relative decrease of platelets in blood.A normal human platelet count ranges from 150,000 to 450,000 platelets per microliter of blood. These limits are determined by the 2.5th lower and upper percentile, so values outside this range do not necessarily indicate disease...
(a low platelet
Platelet
Platelets, or thrombocytes , are small,irregularly shaped clear cell fragments , 2–3 µm in diameter, which are derived from fragmentation of precursor megakaryocytes. The average lifespan of a platelet is normally just 5 to 9 days...
count). If cirrhosis is present, there may be coagulopathy
Coagulopathy
Coagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...
manifested by a prolonged INR; both of these may worsen the hemorrhage from gastric varices.
In very rare cases, gastric varices are caused by splenic vein occlusion as a result of the mass effect of slow-growing pancreatic neuroendocrine tumors.
Diagnosis and classification
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
.
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 varicesEsophageal varices
In medicine , esophageal varices are extremely dilated sub-mucosal veins in the lower esophagus...
. This includes administration of fluids, blood products, and antibiotics.
The results from the only two randomized trials comparing band ligation vs cyanocarylate suggests that endoscopic injection of cyanoacrylate
Cyanoacrylate
Cyanoacrylate is the generic name for cyanoacrylate based fast-acting adhesives such as methyl 2-cyanoacrylate, ethyl-2-cyanoacrylate , and n-butyl 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
Lipiodol also known as ethiodized oil is a poppyseed oil used by injection as a radio-opaque contrast agent that is used to outline structures in radiological investigations. It is used in chemoembolization applications as a contrast agent in follow-up imaging. Lipiodol is also used in...
to prevent polymerization in the endoscopy delivery optics, and to show on radiographic imaging. GVO is usually performed is specialized therapeutic endoscopy centers. Complications include sepsis, embolization of glue, and obstruction from polymerization in the lumen of the stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
.
Other techniques for refractory bleeding include:
- Transjugular intrahepatic portosystemic shunts (TIPS)
- Balloon occluded retrograde transvenous obliteration techniques (BORTO)
- Gastric variceal ligation, although this modality is falling out of favour
- Intra-gastric balloon tamponadeBalloon tamponadeBalloon tamponade usually refers to the use of balloons inserted into the esophagus or stomach, and inflated to stop refractory bleeding from vascular structures—including esophageal varices and gastric varices -- in the upper gastrointestinal tract....
as a bridge to further therapy- a caveat is that a larger balloon is required to occupy the fundusFundus (stomach)The fundus of the stomach is the left portion of the stomach's body, and is marked off from the remainder of the body by a plane passing horizontally through the cardiac orifice....
of the stomach where gastric varices commonly occur
- a caveat is that a larger balloon is required to occupy the fundus
- Liver transplantationLiver transplantationLiver transplantation or hepatic transplantation is the replacement of a diseased liver with a healthy liver allograft. The most commonly used technique is orthotopic transplantation, in which the native liver is removed and replaced by the donor organ in the same anatomic location as the original...
See also
- Gastric antral vascular ectasiaGastric antral vascular ectasia*Please note that Wikipedia does not give medical advice, and that the information in this article is intended to be solely for informational purposes....