Bleeding from gastric varices in portal hypertension: A modern view and the possibility of effective treatment

Horonko Yu.V., Sidorov R.V., Kosovcev E.V., Horonko E.Yu., Tyshlek Yu.V., Krivorotov N.A., Abdullaev K.I., Rudenko O.S.

Esophagogastric variceal bleeding is a life-threatening complication of portal hypertension. At the same time, bleeding from gastric varices, compared with variceal esophageal hemorrhage similar in pathogenesis, is less common, but has more severe complications and high mortality. Features of gastric varices and some variants of their localization can adversely affect the effectiveness of endoscopic hemostasis measures. In such cases, the importance of surgical interventions that provide portal decompression or obliteration of the inflow tracts to the varix increases. First of all, this concerns such endovascular procedures as transjugular intrahepatic portosystemic shunting (TIPS), balloon ante- or retrograde transvenous obliteration, as well as combined techniques. It is known that in majority of clinical cases, variceal bleeding occurs most dramatically in patients with liver cirrhosis. For this reason, the use of minimally invasive rather than transabdominal surgery is preferred. The purpose of the review is to evaluate the current possibilities of effective treatment of bleeding from gastric varices due to portal hypertension.

1. Zatevakhin II, Shipovskii VN, Tsitsiashvili MSh, Monakhov DV. Portal’naya gipertenziya:diagnostika i lechenie. Prakticheskoe rukovodstvo. M.: Buki Vedi, 2015. 328 p. (In Russ.)

2. Roberts D, Best LMJ, Freeman SC, Sutton AJ, Cooper NJ, Arunan S, et al. Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev. 2021; 2021(4): CD013155. doi:10.1002/14651858.CD13155.pub2.

3. Klinicheskie rekomendatsii po lecheniyu krovotechenii iz varikozno rasshirennykh ven pishchevoda I zheludka. Moscow-Voronezh, 2014. 46 p. (In Russ.)

4. De Franchis R, Bosch J, Garcia-Tsao G, Reinberger T, Ripoli C, Baveno VII Faculty. Baveno VII — Renewing consensus in portal hypertension. J Hepatol. 2022; 76(4): 959-974. doi:10.1016/j.jhep.2021.12.022.

5. Boregowda U, Umapathy C, Nalim N, Desai M, Nanjappa A, Arekapudi S [et al.]. Update on the management of gastrointestinal varices. World J Gastroenterol Pharmacol Ther. 2019; 10(1): 1-21. doi: 10.4292/wjgpt.v10.i1.1.

6. Zanetto A, Shalaby S, Feltracco P, Gambato M, Germani G, Russo FP [et al.]. Recent Advances in the Management of Acute Variceal Hemorrhage. J Clin Med. 2021; 10(17): 3818. doi: 10.3390/jcm10173818.

7. Liu P, Hum J, Jou J, Scanian RM, Shatzel J. Transfusion strategies in patients with cirrhosis. Eur J Haematol. 2020; 104(1): 15-25. doi: 10.1111/ejh.13342.

8. He X, Dai Z, Shi P, Hong J. Intravenous Drip of Somatoststin Followed by Restricted Fluid Resuscitation to Treat Upper Gastrointestinal Bleeding in Patients with Liver Cirrhosis. Evid Based Complement Alternat Med. 2021; Oct 13:6548479. doi: 10.1155/2021/6548479.

9. Kola G, Sureshkumar S, Mohsina S, Sreenath GS, Kate V. Restrictive versus liberal transfusion strategy in upper gastrointestinal bleeding: A randomized controlled trial. Saudi J Gastroenterol. 2021; 27(1): 13-19. doi: 10.4103/sjg.SJG_152_20.

10. Samsonyan EKh, Kurganov IA, Bogdanov DYu, Emelianov SI. Endoscopic ligation of esophageal varicose veins in case of ongoing bleeding. Endoskopicheskaya hirurgiya. 2018; 3: 27-32. (In Russ.) doi: 10.1711/endoscop201824327.

11. Yang Z, Xuan J, Yang F, Qi Y, Xu H, Jiang M [et al.]. Timing of endoscopic intervention in patients with cirrhosis with acute variceal haemorrhage (TEACH trial): protocol for a randomised clinical trial (RCT). BMJ Open. 2022; 12(9): e060290. doi.10.1136/bmjopen-2021-060290.

12. Lo GH. The use of Vasoconstrictors in Acute Variceal Bleeding: How Long Is Enough? Clin Endosc. 2019; 52(1): 36-39. doi: 10.5946/ce.2018.084.

13. Gao ZQ, Han Y, Li L, Ding HG. Pharmacological management of portal hypertension: current status and future. Clin Med J (Engl). 2020; 133(19): 2362-2364. doi: 10.1097/CM9.0000000000001004.

14. Pfisterer N, Unger LW, Reiberger T. Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis. World J Hepatol. 2021; 13(7): 731-746. doi: 10.4254/wjh.v13.i7.732.

15. Trebicka J, Macnaughtan J, Schnabl B, Shawcross DL, Bajaj JS. The microbiota in cirrhosis and its role in hepatic decompensation. J Hepatol. 2021; 75(1): S67-S81. doi: 10.1016/j.jhep.2020.11.013.

16. Triantos C, Kalafateli M, Assimakopoulos SF, Karaivazoglou K, Mantaka A, Aggeletopoulou I [et al]. Endotoxin Translocation and Gut Barrier Dysfunction Are Related to Variceal Bleeding in Patients With Liver Cirrhosis. Front Med (Lausanne). 2022; 9: 836306. doi: 10.3389/fmed.2022.836306.

17. Henry Z, Patel K, Patton H, Saad W. AGA Clinical Practice Update on Management of Bleeding Gastric Varices: Expert Review. Clin Gastroenterol Hepatol. 2021; 19(6): 1098-1107. doi: 10.1018/j.cgh.2021.01.027.

18. Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Beyond the scope and the glue: update on evaluation and management of gastric varices. BMC Gastroenterol. 2020; 20: 361. doi: 10.1186/s12876-020-01513-7.

19. Sarin SK, Kumar A. Gastric varices: profile, classification, and management. Am J Gastroenterol. 1989; 84(10): 1244-1249.

20. Singh A, Verma N, Rathi S, Kumari S, Chandel S, Singh V. New Classification of Gastric Varices: A Twenty-Year Experience. J Digest Endosc. 2021; 12(1): 24-30. doi: 10.1055/s-0041-1728222.

21. Maydeo A, Patil G. How to Approach a Patient With Gastric Varices. Gastroenterology. 2022; 162(3): 689-695. doi: 10.1053/j.gastro.2021.12.277.

22. Luo X, Hernández-Gea V. Update on the management of gastric varices. Liver International. 2022; 42: 1250-1258. doi: 10.1111/liv.15181.

23. Tripathy D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H [et al.]. UK guidelines on the management of variceal hemorrhage in cirrhotic patients. Gut. 2015; 64(11): 1680-1704. doi: 10.1136/gutjnl-2015-309262.

24. Oleas R, Robles-Medranda C. Endoscopic Treatment of Gastric Varices. Clin Liver Dis. 2022; 26(1): 39-50. doi: 10.1016/j.cld.2021.08.004.

25. Maruyama H, Shiina S. Collaterals in portal hypertension: anatomy and clinical relevance. Quant Imaging Med Surg. 2021; 11(8): 3867-3881. doi: 10.21037/qims-20-1328.

26. Saad WEA. Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure. Tech Vasc Interv Radiol. 2013; 16(2): 60-100. doi: 10.1053/j.tvir.2013.02.002.

27. Vaz K, Efthymiou M, Vaughan R, Testro AG, Lew HB, Pu LZ. Unpacking the challenge of gastric varices: A review on indication, timing and modality of therapy. World J Hepatol. 2021; 13(8): 868-878. doi: 10.4254/wjh.v13.i8.868.

28. Karstensen JG, Ebitbo A, Bhat P, Dinis-Ribeiro M, Gralnek I, Guy C [et al.]. Endoscopic treatment of variceal upper gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline. Endoscopy International Open. 2020; 8(7): E990-E997. doi: 10.1055/a-1187-1154.

29. Singh GK, Chauhan SG, Sethiya P, Pandey V. Thrombin or glue — you decide. Endoscopy. 2021; 53(2): 210. doi: 10.1055/a-1233-8902.

30. Lo GH, Lin CW, Tai CM, Perng DS, Chen IL, Yeh JH [et al.]. A prospective, randomized trial of thrombin versus cyanoacrylate injection in the control of acute gastric variceal hemorrhage. Endoscopy. 2020; 52(7): 548-555. doi: 10.1055/a-1127-3170.

31. Bick BI, Al-Haddad M, Liangpunsakul S, Ghabril MS, DeWitt JM. EUS-guided fine needle injection is superior to direct endoscopic injection of 2-octyl cyanoacrylate for the treatment of gastric variceal bleeding. Surg Endosc. 2019; 33(6): 1837-1845. doi: 10.1007/s00464-018-6462-z.

32. Robles-Medranda C, Oleas R, Valero M, Puga-Tejada M, Baquerizo-Burgos J, Ospina J, Pitanga-Lukashok H. Endoscopic ultrasonography-guided deployment of embolization coils and cyanoacrylate injection in gastric varices versus coiling alone: a randomized trial. Endoscopy. 2020; 52(4): 268-275. doi: 10.1055/a-1123-9054.

33. Seven G, Musayeva G, Seven OO, Herdan E, Ince AT, Senturk H. Comparison of endoscopic ultrasound-guided coil deployment with and without cyanoacrylate injection for gastric varices. Arab J Gastroenterol. 2022; 23(2): 115-119. doi: 10.1016/j.ajg.2022.04.004.

34. Watanabe 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(2): 434-440. doi: 10.1016/0016-5085(88)9050.

35. Manukyan GV, Malov SL, Musin RA, Zhigalova SB, Lebezev VM, Kitsenko EA, et al. First experience of balloon-occluded retrograde transvenous obliterationof gastric varices. Annaly khirurgicheskoy gepatologii. 2022; 27(2): 58-65. (In Russ.) doi: 10.16931/1995-5464.2022-2-58-64.

36. Lipnik AJ, Pandhi MB, Khabbaz RC, Gaba RC. Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches. Semin Intervent Radiol. 2018; 35(3): 169-184.doi: 10.1055/s-0038-1660795.

37. Gaba RC. Transjugular Intrahepatic Portosystemic Shunt Creation With Embolization or Obliteration for Variceal Bleeding.Tech Vasc Interv Radiol. 2016; 19(1): 21-35. doi: 10.1053/j.tvir.2016.01.003.

38. Schultheiß M, Giesler M, Maruschke L, Schmidt A, Sturm L, Rossle M, et al. Adjuvant Transjugular Variceal Occlusion at Creation of a Transjugular Intrahepatic Portosystemic Shunt (TIPS): Efficacy and Risks of Bucrylate Embolization. Cardiovasc Intervent Radiol. 2019; 42(5): 729-736. doi:10.1007/s00270-019-02176-y.

39. Philips CA, Rajesh S, Augustine P, Padsalgi G, Ahamed R. Portosystemic shunts and refractory hepatic encephalopathy: patient selection and current options. Hepatic Medicine: Evidence and Research. 2019; 11: 23-34. doi: 10.2147/HMER.S169024.

40. Rajesh S, Philips CA, Ahamed R, Abduljaleel JK, Nair DC, Augustine P. Friend or Foe? Spontaneous Portosystemic Shunts in Cirrhosis-Current Understanding and Future Prospects. Can J Gastroenterol Hepatol. 2021; Aug 12: 8795115. doi: 10.1155/2021/8795115.

41. Miyayama S, Yamashiro M, Ikeda R, Matsumoto J, Ogawa N, Sakuragawa N [et al.]. Cerebral Embolism as a Rare Complication of Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices: A Case Report Interv Radiol (Higashimatsuyama). 2021; 6(1): 9-13. doi:10.22575/interventionalradiology.2020-0024.

42. Gwon DI, Ko GY, Yoon HK, Sung KB, Kim JH, Shin JH, et al. Gastric varices and hepatic encephalopathy: treatment with vascular plug and gelatin sponge-assisted retrograde transvenous obliteration — a primary report. Radiology. 2013; 268: 281-287. doi: 10.1148/radiol.13122102.

43. Lee EW, Saab S, Gomes AS, Busuttil R, McWilliams J, Durazo F. [et al.] Coil-Assisted Retrograde Transvenous Obliteration (CARTO) for the Treatment of Portal Hypertensive Variceal Bleeding: Preliminary Results. Clin Transl Gastroenterol. 2014; 5: e61. doi: 10.1038/ctg.2014.12.

44. Mizutani T, Nirei K, Kanda T, Honda M, Ishii M, Arima S,et al. Left Gastric Vein Width Is an Important Risk Factor for Exacerbation of Esophageal Varices Post Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices in Cirrhotic Patients. Medicina (Kaunas). 2022; 58(2): 205. doi: 10.3390/medicina58020205.

45. Waguri N, Osaki A, Watanabe Y. Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices. World J Hepatol. 2021; 13(6): 650-661. doi: 10.4254/wjh.v13.i6.650.

46. Gimm G, Chang Y, Kim HC, Shin A, Cho EJ, Lee JH, et al. Balloon-Occluded Retrograde Transvenous Obliteration vs Transjugular Intrahepatic Portosystemic Shunt for the Management of Gastric Variceal Bleeding. Gut Liver. 2018; 12(6): 704-713. doi: 10.5009/gnl17515.

47. Khoronko YuV, Kozyrevskiy MA, Dmitriev AV, Volokhova AA, Spiridenko YuI, Bogomolova KR. Transjugular portosystemic chunting in refractory cirrhotic ascites. Rossiiskiy zhurnal gastroenterologii, gepatologii, koloproktologii. 2021; 31(1): 39-46. (In Russ.) doi: 10.22416/1382-4376-2021-31-1-39-46.

48. Kotiv BN, Dzidzava II, Alentyev SA, Zubarev PN, Onnitsev IE, Khokhlov AV. Minimally invasive surgical interventions in the treatment and prevention of bleeding from varicose veins of the esophagus and stomach. Izvestiya Rossiyskoy Voenno-meditsinskoy Akademii. 2020; 3: 65-73. (In Russ.)

49. Lin J, Liu Q, Liang Z, He W, Chen J, Ma J. Laparoscopic selective esophagogastric devascularization and splenectomy for patients with cirrhotic portal hypertension. Wideochir Inne Tech Maloinwazyjne. 2019; 14(2): 187-194. doi: 10.5114/wiitm.2018.80297.

50. Zhang Y, Zhang L, Wang M, Luo X, Wang Z, Wang G. Selective Esophagogastric Devascularization in the Modified Sugiura Procedure for Patients with Cirrhotic Hemorrhagic Portal Hypertension: A Randomized Controlled Trial. Can J Gastroenterol Hepatol. 2020; Dec 5: 8839098. doi: Pandhi10.1155/2020/8839098.