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Gastric varices

Overview

Gastric varices are enlarged veins that develop in the stomach as a result of increased pressure in the portal vein that transports blood from the organs of the digestive system to the liver. These varices are similar to oesophageal varices but are located in the stomach.

Gastric varices can be dangerous because, like oesophageal varices, they can rupture and lead to bleeding, which can be life-threatening.

The primary cause of gastric varices is portal hypertension, which can arise from various conditions that affect the liver and the blood flow through it:

  • Cirrhosis: By extension, it is most common cause of gastric varices.
  • Liver disease: Conditions, such as alcoholic liver disease or hepatitis can damage the liver and lead to the development of portal hypertension, which is the primary cause of varices.
  • Portal vein thrombosis: It can lead to portal hypertension as the blood clot in question can obstruct blood flow, and the portal hypertension further leads to the formation of varices in the stomach and other parts of the digestive tract.
  • Schistosomiasis: This parasitic infection can cause liver damage and portal hypertension, leading to the development of varices, including gastric varices.
  • Budd-Chiari syndrome: This rare condition involves obstruction of the hepatic veins, preventing blood from leaving the liver, which can lead to portal hypertension and variceal formation.
  • Congenital disorders: Rare congenital conditions that affect the liver or portal vein can also lead to the development of gastric varices.

In many cases, gastric varices do not produce symptoms until they bleed; however, when symptoms are noticeable, the following can be observed:

  • Upper abdominal pain: This pain can be dull or sharp and may occur in the region occupied by the stomach, i.e., upper left abdomen.
  • Nausea and vomiting: These are especially common when varices are irritated or bleeding.
  • Vomiting blood (hematemesis): This is a sign of bleeding varices.
  • Black, tarry stools (melena): This can indicate bleeding from the gastric varices, as the blood becomes digested in the stomach.
  • Fatigue: This can be attributed to chronic blood loss or the underlying liver disease.
  • Jaundice: This is associated with liver dysfunction and observed when the varices can be attributed to cirrhosis or severe liver disease.
  • Ascites: Fluid accumulation in the abdomen, commonly seen in cirrhosis, which may worsen with portal hypertension.

Gastric varices are diagnosed through a combination of clinical assessment, imaging, and endoscopy:

  • Endoscopy: Upper gastrointestinal endoscopy (EGD) is the most effective way to diagnose gastric varices. During this procedure, a tube-bound camera inserted through the mouth is used to visualise the stomach lining and check for varices. This method can help assess the size, location, and severity of gastric varices, as well as identify active bleeding or other complications.
  • Imaging:
    • CT scan (computed tomography) or MRI: These can be used to assess liver damage, portal hypertension, and varices.
    • Ultrasound with Doppler: This may help detect portal vein abnormalities, liver cirrhosis, and assess blood flow in the portal venous system.
    • Endoscopic ultrasound (EUS): This modality combining endoscopy with ultrasound, allows high-resolution imaging of the varices and nearby structures.
  • Laboratory tests: Blood tests to assess liver function (e.g., liver enzymes, bilirubin, albumin) and look for signs of anaemia (from bleeding) or other complications of portal hypertension can help diagnose gastric varices.

The management of gastric varices primarily focuses on preventing bleeding, treating active bleeding, and managing the underlying cause (such as cirrhosis). Treatment options include:

Prevention of bleeding:

  • Non-specific beta-blockers: Drugs, like propranolol or nadolol can help decrease blood pressure in the portal pressure and prevent variceal bleeding. These are typically used in patients with known varices but no active bleeding.
  • Endoscopic banding or sclerotherapy:
    • Endoscopic variceal ligation (EVL): Also known as banding, this method is commonly used to treat oesophageal varices and may also be used for gastric varices in some cases. A rubber band is placed around the varix to block blood flow and cause the varix to shrink.
    • Endoscopic sclerotherapy: It involves injecting a sclerosing agent into the varices to cause them to close and stop bleeding.
    • Transjugular intrahepatic portosystemic shunt (TIPS): A TIPS procedure creates a bypass, whereby blood from the poral circulation is diverted to the systemic circulation, thereby reducing portal pressure, which by extension, can prevent variceal bleeding. This is often considered for patients with severe portal hypertension and varices that are difficult to manage with other treatments.
  • Management of active bleeding:
    • Octreotide: A somatostatin analogue, octreotide, can help reduce bleeding by lowering portal pressure and constricting blood vessels.
    • Endoscopic treatment: In cases of active bleeding, endoscopic haemostasis techniques (banding, sclerotherapy, or cauterisation) are used to stop the bleeding.
    • Balloon tamponade: In some cases of massive bleeding, a balloon tamponade may be employed to apply pressure to the bleeding varices to control the haemorrhage temporarily until further interventions can be done.
  • Management of the underlying cause: Treating the underlying cause of portal hypertension, such as cirrhosis or liver disease, is essential. This may involve:
    • Antiviral treatments for hepatitis B or C
    • Alcohol cessation in individuals with alcoholic liver disease
    • Liver transplant for end-stage liver disease with severe portal hypertension and varices that cannot be controlled
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