Gastric Varices Treatment: Is it Possible to Individualise Therapy for Bleeding Patients

REVIEW Gastric Varices (GV) are present in 15-25% of cirrhotics with GOV1 and the primary gastric varices being the most common [1]. Gastric varices can also be present in patients with left sided portal hypertension. As compared to esophageal varices the incidence of gastric variceal bleeding is low (10-20%) and bleeding is not proportional to portal pressure as is noted in esophageal varices, with a re bleeding rate of 30% in GV [2,3]. The GV bleeding is difficult to control due to presence of a thick mucosal layer over the GV, which does not collapse after bleeding. With the advent of hemo dynamic studies in GV, there has been change in approach to management of GV. Recently there has been increased focus on individualised GV treatment based on hemo dynamics of the portal system, especially on the left sided venous diseases (GV, ectopic varices, lieno renal shunt) and not on traditionally based endoscopic appearance as is done in most of the cases worldwide. With a contrast CT scan of the portal venous system, it is easy to delineate the anatomy prior to planning a definitive treatment (either primary or secondary). At present the standard treatment for GV is endoscopic glue injection (EGI) by an endoscopist and BRTO (balloon retrograde trans venous obliteration) via intervention radiologist [4-8]. Technically BRTO seems more complete when compared to an EGI, because the whole shunt which drains the GV is taken care of by the BRTO procedure. Whereas in the EGI procedure, only the mucosal varices are treated and the remaining sub mucosal varices, the shunt and the draining pathways (both afferent and efferent) are left untreated. An endoscopic ultrasound (EUS) is a much superior modality of managing vascular disorders such as GV, a. it has col our doppler b. it can differentiate between an artery & a vein c. it can assess shunts & collaterals d. it can assess completion of therapy [9,10]. EUS has been used for treatment of GV from the last decade and it has shown to be technically superior, safe and also it decreases overall cost, number of sessions and morbidity related to re bleeding in GV. With the advent of better diagnostic imaging of the portal venous anatomy such as CT/ MR venography the venous drainage and collaterals can be delineated in patients with GV, this knowledge of the anatomy when combined treatment modalities such as EGI, BRTO or EUS guided vascular treatment helps in individualising the therapy for the patients with GV. In patients of GV with significant collaterals and shunts on the left side of mid line such as (afferent collateralsposterior gastric vein, short