Endoscopic treatment of gastric varices: when and how?

Abstract

Bleeding from gastric varices is less common than from esophageal varices, but when it occurs, it does so more rapidly and profusely, with higher rates of rebleeding and mortality. Therefore, understanding their complex pathophysiology and vascularization is essential, posing a significant endoscopic and therapeutic challenge.

To classify them, the Sarin classification must be used, with fundic varices posing the greatest risk of bleeding and being the focus of this controversy.

When there is active bleeding from fundic varices, treatment must be applied; however, high-quality data to choose the optimal strategy remain limited. Nonetheless, clinical practice guidelines strongly recommend treatment with cyanoacrylate via conventional gastroscopy, as it is an effective, relatively easy, and safe technique to apply in an emergency.

Special precautions must be taken when applying cyanoacrylate due to its complications, the most feared being systemic embolisms. To minimize or even eliminate complications, the combined technique (cyanoacrylate+ coils) guided by endoscopic ultrasound was developed. This treatment modality could be considered the most effective and safe technique, and although it is not yet the preferred choice for acute bleeding, it plays a fundamental role in secondary prophylaxis. It is endorsed by the ESGE guideline and has been included in the research agenda for the upcoming Baveno consensus.

Keywords: gastric varices, treatment, cyanoacrylate, combined technique.