Gastric varices

Disease Description (Causes and Symptoms)

• Definition summary: Gastric varices are a condition in which the blood vessels in and beneath the gastric mucosa become dilated due to portal hypertension (mainly caused by cirrhosis). In particular, fundal varices can cause massive bleeding and have a high mortality rate (approximately 20% in the literature) if they rupture.
• Causes and pathophysiology: When intrahepatic blood-flow resistance increases due to cirrhosis or other conditions, portal pressure rises (portal hypertension), and blood in the abdominal cavity bypasses the liver through collateral veins (communicating veins) in the esophagus and stomach, forming varices. Rupture and bleeding occur when the surface of the varices becomes thin.
• Main symptoms: Hematemesis, hematochezia/melena, symptoms of anemia (fatigue, dizziness), nausea and vomiting, shortness of breath during exercise, cold sweats, and others. Caution is necessary because there is a risk of rupture even when there are no symptoms.

Treatment Methods

1. Emergency management (when bleeding occurs)
   • Basic resuscitation: Securing the airway, providing oxygen, establishing venous access (at least 2 lines), and monitoring vital signs.
   • Blood transfusion: A restrictive transfusion strategy is recommended (generally targeting Hb 7–8 g/dL; a higher target for patients with cardiovascular disease). Massive transfusion may be necessary in cases of severe bleeding.
   • Medication: Vasoconstrictors (such as octreotide or terlipressin) are used to reduce portal pressure.
   • Prophylactic antibiotics: Short-term administration of third-generation cephalosporins (e.g., cefotaxime) is generally used — it is beneficial for reducing the risks of infection, rebleeding, and death.
   • Emergency endoscopy: After the patient is stabilized, upper gastrointestinal endoscopy should be performed as soon as possible (generally recommended within 12 hours) to identify and treat the source of bleeding.
   • Endoscopic treatment: For gastric varices (particularly fundal varices), injection of cyanoacrylate through endoscopic variceal obturation (EVO) is the standard treatment.
   • Temporary adjunctive hemostasis: Balloon tamponade (e.g., Sengstaken–Blakemore tube) may be used depending on the situation, but its effectiveness for gastric varices is limited.
2. Interventions and procedures
   • TIPS (transjugular intrahepatic portosystemic shunt): Considered for patients in whom endoscopic treatment has failed or who are at high risk of rebleeding.
   • BRTO (balloon-occluded retrograde transvenous obliteration): Mainly used as an alternative treatment for fundal varices, particularly when there is a single drainage route.
3. Preventive and conservative treatment
   • Nonselective beta-blockers (NSBBs, e.g., propranolol and nadolol): Used for primary and secondary prevention by lowering portal pressure. Their effectiveness in gastric varices (particularly fundal varices) varies according to location and size, so consultation with the treating physician is necessary.
   • Treatment of the underlying liver disease (treatment of the cause, abstinence from alcohol, treatment of viral hepatitis, etc.) and nutritional management.
4. Complications and post-procedure management
   • Increased risk of hepatic encephalopathy after TIPS — manage with medications such as lactulose when necessary.
   • BRTO may worsen esophageal varices (due to increased portal pressure) — follow-up is necessary.

Checklist Before an Outpatient Visit (Including Preparation and Example Questions)

• Items to bring (helpful for the consultation):
  • A list of medications currently being taken and their doses, including anticoagulants and antiplatelet agents
  • Allergy history (particularly allergies to medications and iodinated contrast media)
  • Previous test results (recent blood tests: Hb, PLT, AST/ALT, bilirubin, INR, etc.) and records of ultrasound, CT, and endoscopic examinations
  • Recent records related to bleeding (the time and amount of hematemesis or melena, whether an emergency-room visit was made, and whether a transfusion was given)
  • Diagnoses related to liver disease (such as cirrhosis and liver cancer) and treatment history
• Information to record before the outpatient visit (to tell the doctor):
  • Whether there have been recent symptoms of gastrointestinal bleeding and when they occurred
  • Whether there is abdominal distension, ascites, confusion (a symptom suggestive of hepatic encephalopathy), or other symptoms
  • The amount and duration of alcohol consumption and medication use (particularly NSAIDs and anticoagulants)
  • Any limitations in daily activities and changes in fatigue

Examples of General Questions to Ask the Doctor

• "In my case, where are the varices located and how large are they, and what is the risk of bleeding?"
• "What medication (such as a beta-blocker) do you recommend to prevent bleeding? What are the side effects?"
• "What should I do immediately if emergency bleeding occurs? When should I go to the emergency room?"
• "How often should follow-up tests (endoscopy, imaging, and blood tests) be performed after treatment?"

Examples of Disease-Specific Questions

• "My gastric varices are located in the fundus. Which treatment should take priority: cyanoacrylate injection (endoscopic obturation) or TIPS? What are the advantages and disadvantages of each method?"
• "I previously received a transfusion due to bleeding. Are there preventive measures (medication or endoscopic treatment) that I should start immediately to reduce the risk of rebleeding?"

If you provide your current test results (endoscopic findings, blood tests, liver-function indicators, Child–Pugh and MELD scores, etc.), more specific recommendations and a list of questions can also be organized.