Management of gastric fundal varices†

Abstract

I read with great interest the guideline for the prevention and management of gastroesophageal varices and variceal hemorrhage in patients with cirrhosis that was approved by the American Association for the Study of Liver Diseases and the American College of Gastroenterology.1 This guideline recommends that the use of a transjugular intrahepatic portosystemic shunt (TIPS) should be considered in patients in whom hemorrhage from fundal varices (FV) cannot be controlled or in whom bleeding recurs despite combined pharmacological and endoscopic therapy. It has been reported that esophageal varices rarely bleed when the hepatic venous pressure gradient (HVPG) is <12 mm Hg or after reduction of the HVPG by 20%, but the hemodynamics of FV are very different from those of esophageal varices or other types of gastric varices. Watanabe et al.2 studied a series of patients with FV and found that most of these varices were associated with a well-developed gastrorenal shunt and that superior mesenteric venous flow was diverted away from the liver and directed into the gastrorenal shunt via the feeding veins for these varices. Accordingly, the HVPG of large FV is quite low, whereas collateral flow into the varices is abundant. In addition, these patients are highly likely to develop hepatic encephalopathy. Tripathi et al.3 reported that bleeding from FV can occur even when the HVPG is <12 mm Hg and that TIPS improves the mortality rate only in patients who suffer from bleeding at an HVPG ≥ 12 mm Hg. This suggests that decompressive procedures such as TIPS are not likely to provide much benefit for FV patients who have a major shunt and low HVPG.4 Obliteration of such FV in a safe manner could therefore be justified. Balloon-occluded retrograde transvenous obliteration (B-RTO) is a radiologic technique using ethanolamine oleate (a common sclerosant) that was developed in Japan for the treatment of FV associated with a gastrorenal shunt.5 B-RTO is similar to TIPS but is less invasive and technically easy for interventional radiologists to perform. B-RTO can achieve excellent long-term prevention of bleeding with few major complications (fever, hemoglobinuria, and worsening of esophageal varices).6, 7 Ninoi et al.8 reported that transcatheter sclerotherapy (including B-RTO) might achieve better control of gastric variceal bleeding than TIPS, and they also suggested that transcatheter sclerotherapy could contribute to a higher survival rate compared with TIPS (class I, level B). The main limitation of B-RTO in the emergency setting seems to be the requirement for temporary control of bleeding with or without use of cyanoacrylate.9 In Japan, B-RTO is a recommended therapeutic option for the treatment of patients who have FV associated with a gastrorenal shunt, regardless of their HVPG or the size of their varices. Multidetector row computed tomographic angiography can accurately assess the presence of a gastrorenal shunt.10 Prospective randomized trials comparing cyanoacrylate with B-RTO are warranted. Akio Matsumoto*, * Department of Internal Medicine, Kumiyama Minami Hospital, Kumiyama-cho, Japan.