Endoscopic devices and techniques for the management of gastric varices (with videos).

Nikhil A Kumta, Ryan J Law, Vinay Chandrasekhara, Erik F Rahimi, Jorge V Obando, Allon Kahn, Andrew P Copland, Samuel Han, Rahul Pannala, Monica Saumoy, Guru Trikudanathan, Amit Bhatt, Julie Yang, Kumar Krishnan, Juan Carlos Bucobo, Arvind J Trindade, David R Lichtenstein, Mansour A Parsi

Journal: Gastrointestinal endoscopy 2025;101(3):496-510

PMID: 39480369

Full Text on Elsevier Science View on PubMed

Abstract

BACKGROUND AND AIMS

Gastric variceal bleeding occurs less commonly than bleeding from esophageal varices (EVs), although it is associated with higher morbidity and mortality. Bleeding from gastroesophageal varices type 1 (GOV1) is treated like EVs. In contrast, other forms of gastric variceal bleeding, including gastroesophageal varices type 2 (GOV2) and isolated gastric varices types 1 (IGV1) and 2 (IGV2), are treated with varying endoscopic approaches. Nonendoscopic methods include transjugular intrahepatic portosystemic shunt (TIPS) or balloon-occluded retrograde transvenous obliteration (BRTO). This technology report focuses on endoscopic management of gastric varices (GVs).

METHODS

The MEDLINE database was searched through August 2022 for relevant articles by using key words such as gastric varices, glue, cyanoacrylate, thrombin, sclerosing agents, band ligation, topical hemostatic spray, coils, EUS, TIPS, and BRTO. The article was drafted, reviewed, and edited by the American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee and approved by the Governing Board of the ASGE.

RESULTS

Endoscopic injection with cyanoacrylate (CYA) glue has been the primary endoscopic method to treat GVs. EUS-guided angiotherapy with CYA glue and coil embolization has emerged as an alternative method enabling improved detection of GVs with a high technical success for targeting and obliterating GVs. Combining CYA glue with coil therapy allows the coil to act as a scaffold for the glue, reducing the risk of glue embolization and improving outcomes. Alternative injectates or topical treatments have been described but remain poorly studied.

CONCLUSIONS

The mainstay paradigm for the endoscopic management of gastric variceal bleeding is the injection of CYA glue. The published success of EUS-guided angiotherapy using CYA glue with or without embolization coils has increased our treatment armamentarium.

Address: Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA.; Department of Gastroenterology, Baylor Scott & White Health, Lakeway, Texas, USA.; Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, Ohio, USA.; Gastroenterology Services, Northwell Health Gastroenterology Institute, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA.; Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.; Division of Gastroenterology and Hepatology, University of Virginia Health Systems, Charlottesville, Virginia, USA.; Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.; Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA.; Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA.; Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA.; Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA.; Division of Gastroenterology, Duke University Health System, Raleigh, North Carolina, USA.; Division of Gastroenterology and Hepatology, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA.; Department of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.; Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA.; Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.

DOI: 10.1016/j.gie.2024.06.038

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MeSH Terms: Humans, Esophageal and Gastric Varices, Gastrointestinal Hemorrhage, Hemostasis, Endoscopic, Cyanoacrylates, Balloon Occlusion, Endoscopy, Gastrointestinal, Endosonography, Tissue Adhesives