How should gastric fundal varices be treated after achieving hemostasis?

Abstract

To the Editor: We read with great interest the article by Arantes and Albuquerque.1Arantes V. Albuquerque W. Fundal variceal hemorrhage treated by endoscopic clip.Gastrointest Endosc. 2005; 61: 732Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar They treated bleeding gastric fundal varices (FV) with endoclips followed by injection of cyanoacrylate. The varices unfortunately bled again, and, subsequently, the patient underwent surgery. The cyanoacrylate used in the present study is supposed to be N-butyl-2-cyanoacrylate (NBCA), which is a widely used agent to stop bleeding from FV. However, because most FV are associated with a gastrorenal shunt,2Watanabe K. Kimura K. Matsutani S. Ohto M. Okuda K. Portal hemodynamics in patients with gastric varices. A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization.Gastroenterology. 1988; 95: 434-440Abstract PubMed Google Scholar injection of NBCA is likely to cause systemic embolization, because of migration of NBCA through the shunt.3Izumiya T. Matsumoto A. Nomura T. Itabashi T. Balloon-occluded retrograde transvenous obliteration as adjunctive treatment for gastric varices: case report.Gastrointest Endosc. 2004; 59: 156-158Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Although we strongly agree with the use of an endoclip to avoid the complication, we think that the existence of a gastrorenal shunt should have been confirmed after achieving initial hemostasis to decide the most appropriate therapeutic strategy. Obliteration of feeding veins as well as FV is important to prevent recurrent bleeding.4Iwase H. Maeda O. Shimada M. Tsuzuki T. Peek R. Nishio Y. et al.Endoscopic ablation with cyanoacrylate glue for isolated gastric variceal bleeding.Gastrointest Endosc. 2001; 53: 585-592Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar Multidetector row CT angiography5Matsumoto A. Takimoto K. Yamauchi Y. Kuchide M. Takemura T. Cost-effective therapeutic strategy for the management of bleeding gastric fundal varices.Endoscopy. 2004; 36: 1031-1032Crossref PubMed Scopus (3) Google Scholar has provided excellent visualization of FV, as well as their feeding and draining veins. The varices treated by Arantes and Albuquerque1Arantes V. Albuquerque W. Fundal variceal hemorrhage treated by endoscopic clip.Gastrointest Endosc. 2005; 61: 732Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar seem to be larger than 12 mm in diameter, therefore, the ratio of cyanoacrylate to contrast medium should have been increased to more than 62.5% or another therapeutic modality should have been selected.6Irisawa A. Obara K. Sato Y. Saito A. Orikasa H. Ohira H. et al.Adherence of cyanoacrylate which leaked from gastric varices to the left renal vein during endoscopic injection sclerotherapy: a histopathologic study.Endoscopy. 2000; 32: 804-806Crossref PubMed Scopus (37) Google Scholar We would like to know the dilution rate and the volume of the agent used in the study. We would also like to know how the authors obliterated the varices. Did they inject cyanoacrylate until the feeding veins were visualized under fluoroscopic monitoring? Because surgery is too invasive and the efficacy of transjugular intrahepatic portosystemic shunting for FV with a low portal pressure gradient seems to be doubtful,7Ryan B.M. Stockbrugger R.W. Ryan J.M. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices.Gastroenterology. 2004; 126: 1175-1189Abstract Full Text Full Text PDF PubMed Scopus (254) Google Scholar we recommend the use of balloon-occluded retrograde transvenous obliteration8Ninoi T. Nishida N. Kaminou T. Sakai Y. Kitayama T. Hamano M. et al.Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients.AJR Am J Roentgenol. 2005; 184: 1340-1346Crossref PubMed Scopus (195) Google Scholar after achieving hemostasis with hemoclip or NBCA for treatment of bleeding from FV associated with a gastrorenal shunt. Fundal variceal hemorrhage treated by endoscopic clipGastrointestinal EndoscopyVol. 61Issue 6PreviewA 34-year-old woman presented in hypovolemic shock from GI bleeding (hematemesis and melena). The initial Hb was 8.6 g/dL (normal: 12-16 g/dL). There was a history of multiple episodes of variceal hemorrhage caused by portal hypertension as a result of schistosomiasis. Emergency EGD revealed a large volume of blood in the stomach and active (spurting) hemorrhage from a large fundal varix (A). Application of an endoclip at the point of rupture of the varix promptly arrested the bleeding (B). When EGD was repeated 3 days later, the clip was still in place. Full-Text PDF ResponseGastrointestinal EndoscopyVol. 63Issue 1PreviewWe are grateful to the valuable comments and questions raised by Dr. Matsumoto and colleagues regarding our brief report on a patient with fundal variceal hemorrhage treated acutely with an endoclip and subsequently with endoscopic injection of cyanoacrylate.1 Before proceeding to the tissue adhesive injection, our patient had submitted to an abdominal US, with findings consistent with hepatosplenic schistosomiasis and no evidence of a gastrorenal shunt. It is of note that her background includes a surgical gastric devascularization with splenic artery ligation 4 years before, making the existence of a gastrorenal shunt less likely. Full-Text PDF