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Abstract

We appreciate the generous comments of Drs. Lo and Lai regarding our recent review of the treatment options for gastric varices (GV). Their comments highlight some of our own contentions regarding GV namely that there are few randomized controlled studies for therapies of GV, and still fewer where GV have been subclassified. The correspondents take issue with our comments regarding the treatment of GOV1. The results of endoscopic variceal sclerotherapy (EVS) for treatment of GOV1 are without doubt better than the results of this treatment for GOV2 or IGV. We acknowledged this data and suggested that EVS is an appropriate option in the treatment of GOV1 but certainly not appropriate in treatment of the other subtypes of GV. In Table 1, the primary hemostasis rate for EVS in GOV1 should have included the lower limit of 67%. We certainly did not intend to imply, nor do we believe that we did imply “between the lines” that EVS is the treatment of choice for treatment of GOV1, but merely that it is an appropriate option. GOV1 are a direct extension of esophageal varices (EV), extending along the lesser curve of the stomach: the distal end of the EV and the proximal margin of the GV is difficult and/or impossible to determine. As a result of this, there has been consensus in the past few years that GOV1 could be treated as for EV,1Sarin S.K. Primignani M. Agarwal S.R. Gastric varices.in: de Franchis R. Portal hypertension. Blackwell Science, London2001: 76-96Google Scholar, 2Jalan R. Hayes P.C. UK guidelines on the management of variceal haemorrhage in cirrhotic patients British Society of Gastroenterology.Gut. 2000; 46: III1-III15PubMed Google Scholar be that with EVS or endoscopic variceal band ligation (EVL). Indeed our own preference is for EVL when the varix size permits, although to date there are no published data for EVL in GOV1. We do not agree with the correspondents contention that “it is now well recognized that EVS is unsuitable in the management of GV,” as several academic bodies cite it as an appropriate option for GOV1, supported by, albeit, incomplete data.2Jalan R. Hayes P.C. UK guidelines on the management of variceal haemorrhage in cirrhotic patients British Society of Gastroenterology.Gut. 2000; 46: III1-III15PubMed Google Scholar We agree that endoscopic variceal obturation (EVO) is highly effective in the treatment of GV of all types, and is the treatment of choice in fundal varices and IGV, and may well be proven to be the treatment of choice for GOV1 also. In the proposed treatment algorithm (Figure 6), we should have included the option of EVO as an alternative to “EV treatment pathways” as a first line treatment of GOV1, as was implicit in the text. We thank Drs. Lo and Lai for their interest in our article and believe that their thoughtful comments again indicate that the optimal treatment of GV still remains to be determined. Randomized controlled studies with accurate subclassification of the GV, adequate patient numbers, and prospective design are needed to answer the many questions that remain. Should GOV1 be treated as for esophageal varices?GastroenterologyVol. 127Issue 3PreviewWe read with interest the review article by Ryan et al. that was published in the April 2004 issue of Gastroenterology.1 This review article made a comprehensive outline of the anatomy, pathophysiology, natural history, and various treatment modalities of gastric varices. We believe that this review article would be greatly helpful to clinicians when facing the formidable bleeding gastric varices. However, the authors suggested that endoscopic variceal sclerosis (EVS) is an effective and appropriate treatment for both treatment of acute GOV1 hemorrhage and for attempting secondary prophylactic GOV1 obliteration. Full-Text PDF