2014 06 manejo de las varices gastricas

8102019 2014 06 Manejo de Las Varices Gastricas

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PERSPECTIVES IN CLINICAL GASTROENTEROLOGYAND HEPATOLOGY

Management of Gastric Varices

Juan Carlos GarciandashPagaacuten Marta BarrufetDagger Andres Cardenassect and Agravengels Escorsellk

Hepatic Hemodynamic Laboratory and kICU Liver Unit Hospital Clinic Institut d rsquo Investigacions Biomegravediques August Pi-Sunyer (IDIBAPS) Ciber de Enfermedades Hepaacuteticas y Digestivas (CIBEREHD) Barcelona DaggerDiagnostic Imaging CenterHospital Clinic Barcelona sectGIEndoscopy Unit Institut de Malalties Digestives i Metaboliques Hospital Cliacutenic University of Barcelona IDIBAPS CIBEREHD Barcelona Spain

This article has an accompanying continuing medical education activity on page e52 Learning ObjectivesmdashAt the end of this activity the successful

learner will understand the prevalence classi1047297cation and therapy of gastric varices in patients with cirrhosis

According to their location gastric varices (GV) are clas-

si1047297ed as gastroesophageal varices and isolated gastric

varices This review will mainly focus on those GV located

in the fundus of the stomach (isolated gastric varices 1 andgastroesophageal varices 2) The 1-year risk of GV bleeding

has been reported to be around 10ndash16 Size of GV

presence of red signs and the degree of liver dysfunction

are independent predictors of bleeding Limited data sug-

gest that tissue adhesives mainly cyanoacrylate (CA) may

be effective and better than propranolol in preventing

bleeding from GV Generalmanagement of acute GV bleeding

must be similar to that of esophageal variceal bleeding

including prophylactic antibiotics a careful replacement of

volemia and early administration of vasoactive drugs Small

samplendashsized randomized controlled trials have shown that

tissue adhesives are the therapy of choice for acute GV

bleeding In treatment failures transjugular intrahepatic

portosystemic shunt (TIPS) is considered the treatment of

choice After initial hemostasis repeated sessions with CA

injections along with nonselective beta-blockers are recom-

mended as secondary prophylaxis whether CA is superior to

TIPS in this scenario is not completely clear Balloon-

occluded retrograde transvenous obliteration (BRTO) has

been introduced as a new method to treat GV BRTO is also

effective and has the potential bene1047297t of increasing portal

hepatic blood 1047298ow and therefore may be an alternative for

patients who may not tolerate TIPS However BRTO oblit-

erates spontaneous portosystemic shunts potentially

aggravating portal hypertension and its related complica-

tions The role of BRTO in the management of acute GV

bleeding is promising but merits further evaluation

Keywords Gastric Varices Variceal Bleeding Portal Hyperten-

sion Cirrhosis Cyanoacrylate Transjugular Intrahepatic Por-

tosystemic Shunt (TIPS) Balloon-occluded Retrograde

Transvenous Obliteration (BRTO)

Prevalence of gastric varices (GV) in patients with

cirrhosis is estimated to be near 17 However

this estimation is based on only one study1 therefore the

actual magnitude of the problem is not well known

According to their location within the stomach GV are

classi1047297ed as gastroesophageal varices (GOV) and isolated

gastric varices (IGV) GOV are divided as GOV1 which are

esophageal varices that extend below the gastroesophageal

junction along the lesser curve of the stomach and GOV2

which are those that extend beyond the gastroesophagealjunction into the fundus of the stomach IGV includes IGV1

which are those located in the fundus of the stomach and

also called fundal varices and IGV2 which refer to ectopic

varices located anywhere in the stomach (Figure 1) This

classi1047297cation initially described by Sarin et al1 has

important clinical implications regarding incidence risk of

bleeding and management According to Sarin et al GOV1

represent almost 75 GOV2 21 IGV1 less than 2 and

IGV2 4 of all GV GOV1 are a continuation of esophageal

varices and share the same vascular anatomy and response

to treatment and thus will not be further discussed This

review will mainly focus on the management of IGV1 andGOV2 the so-called cardiofundal varices Data regarding

prevalence bleeding risk and management of IGV2 are

scarce and therefore no speci1047297c recommendations are

made on this type of GV However in our center the man-

agement of IGV2 is similar to that of IGV1 Although recent

studies speci1047297cally detail the different types of GV most of

the available data comes from series of patients with mixed

types of GV and portal hypertension etiologies (cirrhotic

and noncirrhotic) and the results may not be applicable to

all types of GV As a result the optimal treatment of gastric

fundal varices has not fully been determined

Primary Prophylaxis

In a prospective study including 117 patients with

cirrhosis and cardiofundal varices (69 IGV1 and 31

Abbreviations used in this paper BRTO balloon-occluded retrogradetransvenous obliteration CA cyanoacrylate EBL endoscopic band liga-tion EIS endoscopic injection sclerotherapy EUS endoscopic ultraso-nography GOV gastroesophageal varices GV gastric varices IGVisolated gastric varices RCT randomized controlled trial TIPS trans-

jugular intrahepatic portosystemic shunt

copy 2014 by the AGA Institute1542-3565$3600

httpdxdoiorg101016jcgh201307015

Clinical Gastroenterology and Hepatology 201412919ndash928



GOV2) the incidence of bleeding was 16 36 and

44 at 1 3 and 5 years respectively Size of varices


were directly related with the risk of bleeding (ranging

from an annual incidence of bleeding of 4 in patients

with Child class A with small varices without red signs to

65 in pat ients with Child class C with large varices with

red signs)2 (Figure 2) However these data must be

cautiously interpreted because of the small number of

patients followed for more than 1 year and the unusually

high prevalence (52) of concomitant hepatocelullarcarcinoma The 1-year bleeding risk of the small (n frac14 30)

untreated group of a recent prospective randomized

controlled trial (RCT) comparing cyanoacrylate (CA)

(n frac14 30) vs beta-blockers (n frac14 29) was around 103

Variceal size and liver function evaluated by the Model

for End-Stage Liver Disease score were again factors

associated with a high risk of bleeding In this study GV

were mainly GOV2 with few IGV1 There were signi1047297cant

differences in favor of CA for the prevention of bleeding

and survival when compared with no treatment and only

for prevention of rebleeding when compared with pro-

pranolol However larger studies are needed before a

formal recommendation in regard to the need and typeof primary prophylaxis for GV can be made Until then

our recommendation is not to use primary prophylaxis in

GV or alternatively use nonselective beta-blockers

Management of Acute Gastric VaricealBleeding

Although no studies have been speci1047297cally devoted to

address this issue in patients with cardiofundal varices

general consensus is that the initial management is

similar to that of esophageal variceal bleeding including

the use of prophylactic antibiotics careful replacement of

volemia with a restrictive transfusion policy and the

early administration of vasoactive drugs (terlipressin

somatostatin or a somatostatin analogue)45 IGV1

varices which often appear as a consequence of large

spontaneous splenorenal shunts may bleed with portal

pressure gradients lower than those needed for

esophageal varices It can then be hypothesized that

more powerful vasoconstrictors are needed not only

to decrease portal pressure but also to markedly

reduce portal and collateral blood 1047298ow to control acute

cardiofundal variceal bleeding In our experience

nearly 40 of patients with bleeding IGV1 who wereonly receiving vasoactive drugs require rescue therapy

mainly transjugular intrahepatic portosyst emic shunt

(TIPS) to achieve 5-day control of bleeding6 Therefore

we currently do not recommend using vasoactive drugs

alone but always with concomitant endoscopic therapy

Speci1047297c high-quality data on the use of endoscopic

therapy for acute GV bleeding are limited and in most

published RCTs only half of patients included in the trials

had cardiofundal varices Despite these limitations most

uncontrolled series report a high rate of control of

bleeding with the use of tissue adhesives such as CA

(gt

90) (Table 1) In addition small-size RCTs comparingtissue adhesives vs either endoscopic band ligation (EBL)

or endoscopic injection sclerot herapy (EIS) have shown

that tissue adhesives are equally7 or more89 effective than

EBL in the control of acute bleeding and more effective

than both in preventing rebleeding In addition tissue

adhesives perform better than sclerotherapy in

achieving initial hemostasis910 GOV1 varices are usually

treated as esophageal varices with EBL although some

investigators also recommend the use of tissue

adhesives for GOV1 varices11 Overall experts agree that

endoscopic therapy with tissue adhesives mainly CA is

the therapy of choice for acute bleeding from IGV1 and

GOV241213 If tissue adhesive is not available band

Figure 1 Sarinrsquos classi1047297cation of GV Modi1047297ed with permis-sion from the American Gastroenterological Association(AGA) Institute Gastroslides ndash Cirrhosis and PortalHypertension

Figure 2 A large gastric varix (IGV1) with a recent nipple sign

920 GarciandashPaga n et al Clinical Gastroenterology and Hepatology Vol 12 No 6



ligation seems to have some bene1047297t in small GOV2 varices

However no speci1047297c studies have evaluated this issue5

The standard protocol uses CA and lipiodol in 11ratio injecting with no more than 1 mL at the varix each

time14 (Supplementary Video) In most cases CA is

usually extruded into t he stomach lumen within 1ndash3

months after injection15 Multiple complications from CA

injection have been reported among published studies A

recent report of 753 patients indicated that most com-

plications occurred from rebleeding that was due to

extrusion of the glue cast (44) sepsis (13) distant

emboli (pulmonary cerebral splenic 07) gastric ulcer

formation (01) major gastric variceal bleeding (01)

and mesenteric hematoma associated with hemoper-

itoneum and bacterial peritonitis (01) The complica-tion-related mortality was 0516 Other studies have

reported a higher incidence of embolism that may occur

in up to 2ndash3 of cases1317

Combination therapy of endoscopy and pharmaco-

logic therapy is considered the st andard of care in acute

esophageal variceal bleeding45 However because of

the paucity of data it is unknown whether this

recommendation also applies to GOV2 or IGV1 variceal

bleeding Because in most cases drug therapy is

started before diagnostic endoscopy (and therefore

before the identi1047297cation of the gastric variceal origin

of bleeding) it seems the most rational approach is to

combine drug therapy plus endoscopic treatment

(preferably tissue adhesives) in patients with acute GV

bleeding

In massive bleeding with hemodynamic instabilityballoon tamponade can be used as a temporary ldquobridgerdquo

(for a maximum of 24 hours) until de1047297nitive treatment

can be instituted Tamponade may achieve hemostasis

in up to 80 of the patients although more than 50

of the cases rebleed af ter balloon de1047298ation A single

study from Teres et al18 comparing the LintonndashNachlas

vs the SengstakenndashBlakemore tube demonstrated that

LintonndashNachlas tube was more effective in fundal var-

iceal bleeding because of the large volume (600 mL) of

its single gastric balloon allowing an appropriate

compression of the fundal varices Nevertheless if the

Lintonndash

Nachlas balloon is not available compressionwith the gastric balloon of a SengstakenndashBlakemore

tube maximally in1047298ated may be appropriate

TIPS is considered the treatment of choice in patients

bleeding from GOV2 or IGV1 after failure to control initial

bleeding or rebleeding with combination therapy1920

Contrary to what is suggested in esophageal variceal

bleeding a second-attempt endoscopic therapy is

usually not considered Embolization of collaterals

feeding GV has been proposed to increase the ef 1047297cacy of

the TIPS procedure Two retrospective studies analyzed

the ef 1047297cacy of embolization combined with TIPS in acute

variceal bleeding Few patient s with cardiofundal

variceal bleeding (2121 and 3122 respectively) were

Table 1 Results of Published Studies on Endoscopic Treatment of Acute Bleeding From GV

First author year (reference) Design n

Treatmentreceived (n)

Initial control ( )overall (according

to treatment)

Mortality ( )overall (according to

treatment)Follow-up a

( mo )

Ogawa 199969 Retros 33 EIS (21) vs glue (12) 67 (53 vs 100) NR mdash

Kind 200070 Obs 174 Glue 97 64 36Huang 200071 Obs 90 Glue 100 40 36

Akahoshi 200272 Obs 52 Glue 96 30 12Rengstorff 200473 Pilot 25 Glue 100 12 11Mahadeva 200323 Obs 43 TIPS (20) vs

glue (23)93 (90 vs 96) 20 (25 vs 15) 6

Cheng 200730 Obs 146 Glue 95 10 36Mumtaz 200774 Obs 50 Glue 100 12 In-hospitalMarques 200828 Obs 48 Glue 88 44 18Paik 200875 Obs 121 Glue 91 12 1Procaccini 200944 Retros 105 TIPS (61) vs

glue (44)91 (90 vs 93) NR mdash

Monsanto 201276 Obs 97 Glue 96 9 In-hospitalOho 19959 RCT 53 EIS (24) vs

glue (29)81 (50 vs 88) 53 (67 vs 38) mdash

Lo 20018 RCT 26 EBL (11) vs glue (15) 69 (45 vs 87) 42 (48 vs 29) 24Sarin 200210 RCT 17 EIS (8) vs

glue (9)59 (38 vs 78) 18 (25 vs 11) 16

Tan 20067 RCT 97 EBL (48) vsglue (49)

93 (93 vs 93) 64 (63 vs 65) 36

Hou 200977 RCT 91 Glue (05 vs10 mL)

88 NR mdash

NOTE All the studies included IGV1 GOV1 and GOV2Obs observational study Retros retrospective comparative study aMedian

June 2014 Management of Gastric Varices 921



included No 1047297rm conclusions can be drawn from these

small studies However although evidence on the target

portal pressure gradient to be reached to prevent

rebleeding from fundal GV is not clear and it has been

suggested that fundal varices may rebleed despite a

portal pressure gradient slightly below 12 mm Hg the

small previous studies suggest that there is not a clear

rationale to perform embolization particularly if theportal pressure gradient after TIPS is reduced below 12

mm Hg

There is no RCT evaluating the use of TIPS as the

initial treatment to achieve hemostasis in patients with

IGV1 a cohort study suggested that it is highly effective

in achieving initial hemostasis in GOV1 and GOV2 vari-

ces23 A recent RCT showed that early (72 hours from

bleeding) polytetra1047298uoroethylene-coated TIPS can be

considered as a 1047297rst-line treatment in patients with

esophageal variceal bleeding at high risk of treatment

failure (de1047297ned by Child class C less than 14 points or

Child class B with active bleeding) because it reduces the

risk of treatment failure and improves survival in com-

parison with convent ional treatment with drugs plus

endoscopic therapy24 Although patients with GV were

excluded in the study it is likely that the bene1047297t of the

use of early TIPS may also apply to patients with GV and

the same high-risk criteria however this needs to be

studied further

Secondary Prophylaxis

Rebleeding rates after an acute GV bleeding episode

treated with tissue adhesives (mainly CA) range from7ndash65 with most of the large series reporting rates

below 15 Thus after initial hemostasis with tissue

adhesives repeated sessions are performed on a 2- to

4-week basis until endoscopic obliteration is achieved

Several case series and controlled studies have specif-

ically evaluated the effect of long-term injections

of tissue adhesives (mainly CA) to prevent GV

rebleeding1725ndash30 (Table 2) In most of these studies

eradication is achieved with 2ndash4 injections with a

volume ranging from 1ndash2 mL per session

Similar to what occurs with initial hemostasis CA

has been shown to be superior to both sclerotherapy

and band ligation for secondary prophylaxis On the

contrary comparison with nonselective beta-blockers

offers con1047298icting results In a small randomized study

41 patients who bled from esophageal (n frac14 31) or GV

(GOV 1 and GOV 2) (n frac14 10) treated initially with CA

were randomized to repeated CA injections (n frac14 21) or

propranolol (80ndash160 mg) (n frac14 20)31 No signi1047297cant

differences were observed between the 2 groups in theincidence of variceal rebleeding and death The inci-

dence of complications was higher in the CA group

(47 vs 10) A major limitation of the study was the

small number of patients with GV31 In a more recent

RCT 64 patients who bled from GV (54 GOV 2 and

10 IGV1) were allocated to receive either repeated CA

(n frac14 33) or propranolol (n frac14 34) for secondary pro-

phylaxis32 Rebleeding in the CA group was signi1047297cantly

lower than in the beta-blocker group (15 vs 55

P frac14 004) and after a 26-month follow-up the mortality

rate was lower as well (3 vs 25 P frac14 026) The rate

of complications in the CA group was 3

A recent report indicates that endoscopic ultraso-

nography (EUS)ndashguided therapy for fundal GV (IGV1 and

GOV2) with CA and 1047297bered coils may improve the ef 1047297-

cacy of this technique33 In this study 30 patients un-

derwent successful transesophageal EUS-guided therapy

of IGV1 and GOV2 The mean number of GV treated was

13 per patient and the mean volume of CA injected was

14 mL per varix GV were obliterated after a single

treatment session in the vast majority of patients (96)

who underwent follow-up endoscopy Rebleeding

occurred in 1 patient who was successfully treated with

a second session There were no procedure-related

complications Although this is a small series EUS-guidedtherapy seems to be a promising approach in selected

cases however more data are needed to consider it a

routine tool for the management of GV

Finally in a recent study 95 patients with GV (GOV2

n frac14 77 IGV1 n frac14 18) who bled and were successfully

treated with CA were assigned to receive treatment with

beta-blockers plus repeated CA (every 3ndash4 weeks until

the varices were obliterated) or repeated CA injections

alone34 After a mean follow-up of 19 months the overall

rebleeding (22 vs 26 patients P frac14 336) and survival

rates (22 vs 20 P frac14 936) were not different between the

2 groups One-year rebleeding free survival was also

Table 2 Results of Published Studies on Long-term Injection of Tissue Adhesives in the Prevention of GV Rebleeding

First author year (reference) n Eradicationhemostasis ( ) Rebleeding ( )

Follow-up(median) Survival ( ) Complications ( )

Rajoriya 201125 31 90 10 4 y 65 (1 y) 64Mishra 201032 33 100 10 26 mo 90 (2 y) 3Choudhuri 201026 108 89 10 307 thorn 172 mo NA NA Belletrutti 200827 34 84 12 11 mo 82 (1 y) 3Marqueacutes 200828 48 87 20 18 mo 56 (NA) 6Cheng 200730 613 77 8 25 mo 95 (1 y) 5Joo 200717 85 98 29 24 mo NA 35




similar (77 vs 765) The results of this study suggest

that contrary to what has been demonstrated for

esophageal variceal bleeding adding beta-blocker ther-

apy to repeated sessions of CA provides no important

bene1047297t for prevention of rebleeding and mortality in

patients with GV bleeding Despite these 1047297ndings and

because nonselective beta-blockers are effective in pa-

tients with concomitant esophageal varices until largerstudies with longer follow-up are available we still

recommend the use of nonselective beta-blockers as an

adjunct to endoscopic therapy in the prevention of GV

rebleeding

Other Endoscopic Therapies

Other endoscopic treatments have also been used to

prevent rebleeding Sclerotherapy has been abandoned

because of high rebleeding rates (50ndash90) Variceal

band ligation may be used for those patients with GOV1

and in some cases of small GOV2 and it is generallyperformed every 2 weeks until apparent endoscopic

obliteration However band ligation is limited by the fact

that it cannot be used in large GOV2 or IGV17 Detachable

loop snares to treat large GV (gt2 cm) along with pro-

pranolol have resulted in low rebleeding rates however

data are very scarce and the procedure is labor inten-

sive This approach has not been further evaluated and

has not been compared with other modalities and thus

cannot be routinely recommended

Thrombin

Thrombin converts 1047297brinogen to a 1047297brin clot thus

forming a clot inside the GV and occluding blood 1047298ow

The use of bovine thrombin was banned because of the

risk of potential prion transmission This is not the case

when using commercially available human thrombin

Each vial is reconstituted with 5 mL distilled water for a

concentration of 250 UmL35 The average dose of

injected thrombin ranges between 1500 and 2000 U

Available data indicate that thrombin is safe and effective

in the treatment of acute GV bleeding with hemostasis

rates of 70ndash100 however rebleeding rates may

range from 7ndash

5036ndash41

There are scarce data inregard to follow-up and eradication rates After initial

hemostasis repeated thrombin injections are

performed every 2ndash3 weeks until eradication Because

of the paucity of data mostly coming from case series

the routine use of thrombin cannot be routinely

recommended

Transjugular Intrahepatic PortosystemicShunt

The role of TIPS vs CA in preventing GV bleeding has

been evaluated in 3 small studies (2 retrospective

observational studies and 1 prospective) Remarkablyin all

3 studies most patients included had GOV1a fewGOV2 and

only anecdotal IGV1 varices In addition the stents used

were uncoated which hasbeen shownto be associatedwith

lower TIPS patency ef 1047297cacy and survival than coated

stents42 Two of these studies2343 showed a higher

rebleeding rate in the CA group (30 and 59) vs the

TIPS group (15 and 40) (Supplementary Table 1)Frequency of complications was similar in the 2 groups

but TIPS-treated patients showed a higher incidence of

hepatic encephalopathy234344 and long-term morbidity

requiring hospitalization44 than endoscopically treated

patients The studies found no signi1047297cant differences in

survival Mahadeva et al23 analyzed the costs after 6

months of therapy and found that CA injections were

more cost-effective than TIPS in a small group of 43

patients with GV bleeding In summary TIPS is a very

effective therapy to prevent GV rebleeding Nevertheless

because of the previously mentioned drawbacks more

data are needed to clarify the role of TIPS in the

secondary prophylaxis of GV bleeding and determine

whether this therapy must be universally applied or

reserved as a rescue therapy after failure of more

conservative approaches

Surgery

Surgery has currently fallen out of favor for patients

with portal hypertension because of the wide avail-

ability of less invasive techniques such as endoscopy

and interventional radiology In selected cases pa-

tients with GV and segmentalleft-sided portal hyper-

tension that is due to isolated splenic vein thrombosis

may be candidates for splenectomy or splenic emboli-

zation as a means of de1047297nitive therapy however data

are scarce

Balloon-occluded RetrogradeTransvenous Obliteration

Balloon-occluded retrograde transvenous obliteration

(BRTO) has been introduced as a treatment method that

aims to directly oblit erate the GV Since its introduction

by Kanagawa et al

45

BRTO has become widely acceptedin Japan and in some centers in the United States as a

minimally invasive and highly effective treatment for GV

The technical dif 1047297culty of BRTO relies on the anatomy of

the afferent and draining veins of the GV Accurate

assessment which is mainly based on imaging studies of

the variceal hemodynamic pattern is the most important

factor in ensuring successful treatment This anatomy

and how it alters the approach have been t horoughly

reviewed by Hirota et al46 Kiyosue et al4748 and

Al-Osaimi et al49

In most cases there is a gastrorenal or gastrocaval

shunt In this situation under 1047298uoroscopic guidance a

balloon catheter is inserted into the outlet of the




gastrorenal or gastrocaval shunt through a sheath placed

in the right femoral vein Immediately afterward

venography is performed with an injection of 10ndash15 mL

contrast medium via the in1047298ated balloon catheter and

GV are slowly intermitt ently and completely 1047297lled with

a sclerosant (Figure 3)454650ndash63 Thirty to 50 minutes

after the injection as much of the remaining sclerosant

as possible is aspirated via the catheter Finally the

balloon is de1047298ated and the catheter is withdrawn

Ethanolamine oleate is the predominant and traditional

sclerosant agent used in the BRTO procedure

particularly in Asia454650ndash60 Detergent sclerosants in a

foam or frot h have also been studied in both Japan

(polidocanol)6162 and the United States (3 STS)63

Figure 3 ( A ) Basic porto-systemic venous anatomyof GV with the classic gas-trorenal or splenorenalshunts ( B ) ConventionalBRTO procedure throughtransfemoral approach withballoon in the gastrorenalshunt IVC inferior venacava LGV left gastric veinLRV left renal vein MV

mesenteric vein PGVposterior gastric vein(s)PV main portal vein SGVshort gastric vein(s) SVsplenic vein Afferent vein( thin arrows ) Drainage vein( thick arrow )




The advantage of foam is that it reduces the sclerosant-

to-volume ratio requiring less sclerosant per procedure

In cases that involve complex types of afferent or

draining veins the use of additional techniques is required

for successful treatment These techniques include step-wise injection of the sclerosing agent selective injection of

the agent via a microcatheter coil embolization of the

afferent gastric veins double-balloon catheterization and

BRTO performed with percutaneous transhepatic portal

venous access or transileocolic venous access48

Epigastric and back pain (76)56 fever (26)5660

and transient hematuria (53) are the most common

complications of BRTO Bacterial peritonitis was found in

8 of patients in one study but t hese patients recovered

after only conservative therapy45 and this complication is

otherwise rarely mentioned in the literature Portal

(43) and renal vein thrombosis (5) can be found in asmall number of patients and bot h are usually clinically

silent465059 Pulmonary embolism59 pulmonary edema61

coil migration46 and anaphylaxis to ethanolamine oleate46

have also been reported

Technical success de1047297ned by complete obliteration of

the GV with sclerosant occurs in 77ndash100 of pa-

tients64 In some studies repeat BRTO was necessary to

achieve such high percentages465260 GV bleeding af t er a

successful BRTO ranges from 0ndash15465052555659ndash6165

or from 0ndash31666 when factoring in an intent-to-treat

basis (including technical failures) Some authors suggest

that BRTO might be better than TIPS67 or glue65 in the

prevention of GV bleeding However the fact that in

most patients treatment was administered as primary

prophylaxis for high-risk GV the studies had a small

sample size and the ef 1047297cacy of the comparative groups

(either TIPS or glue therapy) was poorer than expected

precludes de1047297nitive conclusions There is only a smallstudy54 that randomized 15 patients with acute GV

bleeding to receive TIPS (n frac14 7) or BRTO (n frac14 8)

without observing signi1047297cant differences in rebleeding

hepatic encephalopathy or survival

BRTO has the potential advantage of increasing portal

blood 1047298ow and potentially improving liver function525457

Therefore it may represent an alternative in patients who

may otherwise not tolerate TIPS59 In that regard in 4

studies including patients with hepatic encephalopathy

there was resolution or signi1047297cant reduction in

encephalopathy in all patients after BRTO46505158 By

contrast BRTO obliterates a spontaneous portosystemicshunt and therefore aggravates portal hypertension and

its related complications An increase in the size of

esophageal varices and the risk of esophageal variceal

bleeding after BRTO has been reported (between 73

and 27 after 1 year)525556 Other complications related

to the increase of portal hypertension after BRTO are the

development of portal hypertensive gastropathy (in 5ndash

13 of cases) ascites (0ndash44)65 and hydrothorax

pleural effusion (0ndash72) As a consequence of the

worsening of portal hypertension in some cases TIPS has

been performed after BRTO68

In conclusion although BRTO seems to be a feasible

technique that is able to successfully control and prevent

Figure 4 Suggested algo-rithm for management of GV EBL in small GV if tissue adhesives notavailable HE hepaticencephalopathy




GV bleeding there is a lack of good quality data to

routinely recommend BRTO in the management of GV In

our opinion BRTO could be considered in patients with

GV bleeding and large gastrorenal shunts in whom TIPS

may be contraindicated (such as those with refractory

hepatic encephalopathy or elderly patients)

Summary

The best management strategy for GV has not been

completely established because of a paucity of data of

RCTs in this area Speci1047297c treatments such as CA injec-

tion and BRTO are not widely available in all centers

Another limitation is the fact that tissue adhesives such

as CA are not approved by the Food and Drug Adminis-

tration in the United States and thus recommendations

arising from published studies guidelines and expert

opinion cannot be extrapolated to routine practice We

recommend a stepped care approach to the management

of GV as described in Figure 4 There are scarce data onthe role of CA or beta-blockers for primary prophylaxis

of GV bleeding and thus speci1047297c recommendations

cannot be made however patients should receive beta-

blockers if they have concomitant esophageal varices

After initial resuscitation and implementation of vaso-

constrictors and antibiotics endoscopic therapy with CA

should be the 1047297rst line of therapy if available After the

acute episode patients should receive beta-blockers

along with repeated sessions of CA injection if available

TIPS is very effective in controlling active GV bleeding

and for secondary prophylaxis However it carries a risk

of hepatic encephalopathy TIPS is the best treatment

strategy for patients who fail endoscopic therapy

Supplementary Material

Note To access the supplementary materials accom-

panying this article visit the online version of Clinical

Gastroenterology and Hepatology at wwwcghjournalorg

and at httpdxdoiorg101016jcgh201307015

References1 Sarin SK Lahoti D Saxena SP et al Prevalence classi1047297cation

and natural history of gastric varices a long-term follow-upstudy in 568 portal hypertension patients Hepatology 1992161343ndash1349

2 Kim T Shijo H Kokawa H et al Risk factors for hemorrhagefrom gastric fundal varices Hepatology 199725307ndash312

3 Mishra SR Sharma BC Kumar A et al Primary prophylaxis of gastric variceal bleeding comparing cyanoacrylate injection andbeta-blockers a randomized controlled trial J Hepatol 2011541161ndash1167

4 de Franchis R Revising consensus in portal hypertensionreport of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension J Hepatol 201053762ndash768

5 Garcia-Tsao G Sanyal AJ Grace ND et al Prevention andmanagement of gastroesophageal varices and variceal hemor-

rhage in cirrhosis Hepatology 200746922ndash938

6 Escorsell A Abraldes JG Pipa-Muntildeiz M et al Prognosis of acute bleeding from isolated fundal varices in patients withcirrhosis a European cohort Hepatology 201256(Suppl)748A

7 Tan PC Hou MC Lin HC et al A randomized trial of endoscopictreatment of acute gastric variceal hemorrhage N-butyl-2-cyanoacrylate injection versus band ligation Hepatology 200643690ndash697

8 Lo GH Lai KH Cheng JS et al A prospective randomized trial

of butyl cyanoacrylate injection versus band ligation in themanagement of bleeding gastric varices Hepatology 2001331060ndash1064

9 Oho K Iwao T Sumino M et al Ethanolamine oleate versusbutyl cyanoacrylate for bleeding gastric varices a non-randomized study Endoscopy 199527349ndash354

10 Sarin SK Jain AK Jain M et al A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolatedfundic varices Am J Gastroenterol 2002971010ndash1015

11 Lo GH Lai KH Should GOV1 be treated as for esophagealvarices Gastroenterology 20041271014ndash1015

12 Greenwald BD Caldwell SH Hespenheide EE et al N-2-butyl-cyanoacrylate for bleeding gastric varices a United States pilot

studyand cost analysis Am J Gastroenterol 2003981982ndash1988

13 Caldwell SH Hespenheide EE Greenwald BD et al Enbucrilatefor gastric varices extended experience in 92 patients AlimentPharmacol Ther 20072649ndash59

14 Seewald S Ang TL Imazu H et al A standardized injectiontechnique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundalvarices (with videos) Gastrointest Endosc 200868447ndash454

15 Wang YM Cheng LF Li N et al Study of glue extrusion after endoscopic N-butyl-2-cyanoacrylate injection on gastric vari-ceal bleeding World J Gastroenterol 2009154945ndash4951

16 Cheng LF Wang ZQ Li CZ et al Low incidence of complica-tions from endoscopic gastric variceal obturation with butyl

cyanoacrylate Clin Gastroenterol Hepatol 20108760ndash766

17 Joo HS Jang JY Eun SH et al [Long-term results of endo-scopic histoacryl (N-butyl-2-cyanoacrylate) injection for treat-ment of gastric varices a 10-year experience] Korean JGastroenterol 200749320ndash326

18 Teres J Cecilia A Bordas JM et al Esophageal tamponadefor bleeding varices controlled trial between the Sengstaken-Blakemore tube and the Linton-Nachlas tube Gastroenterology197875566ndash569

19 Chau TN Patch D Chan YW et al ldquoSalvagerdquo transjugular intrahepatic portosystemic shunts gastric fundal compared withesophageal variceal bleeding Gastroenterology 1998114981ndash987

20 Azoulay D Castaing D Majno P et al Salvage transjugular intrahepatic portosystemic shunt for uncontrolled varicealbleeding in patients with decompensated cirrhosis J Hepatol200135590ndash597

21 Gaba RC Bui JT Cotler SJ et al Rebleeding rates followingTIPS forvariceal hemorrhage in the Viatorr era TIPS alone versusTIPS with variceal embolization Hepatol Int 20104749ndash756

22 Xiao T Chen L Chen W et al Comparison of transjugular intrahepatic portosystemic shunt (TIPS) alone versus TIPScombined with embolotherapy in advanced cirrhosis a retro-spective study J Clin Gastroenterol 201145643ndash650

23 Mahadeva S Bellamy MC Kessel D et al Cost-effectivenessof N-butyl-2-cyanoacrylate (histoacryl) glue injections versus trans-

jugular intrahepatic portosystemic shunt in the management of


Edso nGuzman FirmadodigitalmenteporEdso nGuzmanNombredereconocimiento(D N)cn=EdsonGuzmanoou=HNERMemail=e dson_guzmanhotmailcomc=PEFecha20140526200159-050 0



acute gastric variceal bleeding Am J Gastroenterol 2003982688ndash2693

24 Garcia-Pagan JC Caca K Bureau C et al Early use of TIPS inpatients with cirrhosis and variceal bleeding N Engl J Med 20103622370ndash2379

25 Rajoriya N Forrest EH Gray J et al Long-term follow-up of endoscopic Histoacryl glue injection for the management of gastric variceal bleeding QJM 201110441ndash47

26 Choudhuri G Chetri K Bhat G et al Long-term ef 1047297cacy andsafety of N-butylcyanoacrylate in endoscopic treatment of gastric varices Trop Gastroenterol 201031155ndash164

27 Belletrutti PJ Romagnuolo J Hilsden RJ et al Endoscopicmanagement of gastric varices ef 1047297cacy and outcomes of gluingwith N-butyl-2-cyanoacrylate in a North American patient pop-ulation Can J Gastroenterol 200822931ndash936

28 Marques P Maluf-Filho F Kumar A et al Long-term outcomesof acute gastric variceal bleeding in 48 patients followingtreatment with cyanoacrylate Dig Dis Sci 200853544ndash550

29 Fry LC Neumann H Olano C et al Ef 1047297cacy complications andclinical outcomes of endoscopic sclerotherapy with N-butyl-2-cyanoacrylate for bleeding gastric varices Dig Dis 200826

300ndash30330 Cheng LF Wang ZQ Li CZ et al Treatment of gastric varices by

endoscopic sclerotherapy using butyl cyanoacrylate 10 yearsrsquoexperience of 635 cases Chin Med J (Engl) 20071202081ndash2085

31 Evrard S Dumonceau JM Delhaye M et al Endoscopic histo-acryl obliteration vs propranolol in the prevention of esoph-agogastric variceal rebleeding a randomized trial Endoscopy200335729ndash735

32 Mishra SR Chander SB Kumar A et al Endoscopic cyanoac-rylate injection versus beta-blocker for secondary prophylaxis of gastric variceal bleed a randomised controlled trial Gut 201059729ndash735

33 Binmoeller KF Weilert F Shah JN et al EUS-guided trans-esophageal treatment of gastric fundal varices with combinedcoiling and cyanoacrylate glue injection (with videos) Gastro-intest Endosc 2011741019ndash1025

34 Hung HH Chang CJ Hou MC et al Ef 1047297cacy of non-selectivebeta-blockers as adjunct to endoscopic prophylactic treatment for gastric variceal bleeding a randomized controlled trial J Hepatol2012561025ndash1032

35 McAvoy NC Plevris JN Hayes PC Human thrombin for thetreatment of gastric and ectopic varices World J Gastroenterol2012185912ndash5917

36 Krystallis C McAvoy NC Wilson J et al EUS-assisted thrombininjection for ectopic bleeding varices a case report and review

of the literature QJM 2012105355ndash

35837 Ramesh J Limdi JK Sharma V et al The use of thrombininjections in the management of bleeding gastric varices a single-center experience Gastrointest Endosc 200868877ndash882

38 Heneghan MA Byrne A Harrison PM An open pilot study of theeffects of a human 1047297brin glue for endoscopic treatment of pa-tients with acute bleeding from gastric varices GastrointestEndosc 200256422ndash426

39 Yang WL Tripathi D Therapondos G et al Endoscopic use of human thrombin in bleeding gastric varices Am J Gastroenterol2002971381ndash1385

40 Przemioslo RT McNair A Williams R Thrombin is effective inarresting bleeding from gastric variceal hemorrhage Dig Dis Sci199944778ndash781

41 Williams SG Peters RA Westaby D Thrombin an effectivetreatment for gastric variceal haemorrhage Gut 1994351287ndash1289

42 Yang Z Han G Wu Q et al Patency and clinical outcomesof transjugular intrahepatic portosystemic shunt with poly-tetra1047298uoroethylene-covered stents versus bare stents a meta-analysis J Gastroenterol Hepatol 2010251718ndash1725

43 Lo GH Liang HL Chen WC et al A prospective randomized

controlled trial of transjugular intrahepatic portosystemic shuntversus cyanoacrylate injection in the prevention of gastric vari-ceal rebleeding Endoscopy 200739679ndash685

44 Procaccini NJ Al-Osaimi AM Northup P et al Endoscopiccyanoacrylate versus transjugular intrahepatic portosystemicshunt for gastric variceal bleeding a single-center US analysisGastrointest Endosc 200970881ndash887

45 Kanagawa H Mima S Kouyama H et al Treatment of gastricfundal varices by balloon-occluded retrograde transvenousobliteration J Gastroenterol Hepatol 19961151ndash58

46 Hirota S Matsumoto S Tomita M et al Retrograde transvenousobliteration of gastric varices Radiology 1999211349ndash356

47 Kiyosue H Mori H Matsumoto S et al Transcatheter oblitera-

tion of gastric varices part 2mdashstrategy and techniques basedon hemodynamic features Radiographics 200323921ndash937

48 Kiyosue H Mori H Matsumoto S et al Transcatheter oblitera-tion of gastric varices part 1mdashanatomic classi1047297cation Radio-graphics 200323911ndash920

49 Al-Osaimi AM Sabri SS Caldwell SH Balloon-occluded retro-grade transvenous obliteration (BRTO) preprocedural evalua-tion and imaging Semin Intervent Radiol 201128288ndash295

50 Cho SK Shin SW Lee IH et al Balloon-occluded retrogradetransvenous obliteration of gastric varices outcomes andcomplications in 49 patients AJR Am J Roentgenol 2007189W365ndashW372

51 Sonomura T Sato M Kishi K et al Balloon-occluded retrograde

transvenous obliteration for gastric varices a feasibility studyCardiovasc Intervent Radiol 19982127ndash30

52 Fukuda T Hirota S Sugimura K Long-term results of balloon-occluded retrograde transvenous obliteration for the treatmentof gastric varices and hepatic encephalopathy J Vasc IntervRadiol 200112327ndash336

53 Kitamoto M Imamura M Kamada K et al Balloon-occludedretrograde transvenous obliteration of gastric fundal varices withhemorrhage AJR Am J Roentgenol 20021781167ndash1174

54 Choi YH Yoon CJ Park JH et al Balloon-occluded retrogradetransvenous obliteration for gastric variceal bleeding its feasi-bility compared with transjugular intrahepatic portosystemicshunt Korean J Radiol 20034109ndash116

55 Ninoi T Nishida N Kaminou T et al Balloon-occluded retro-grade transvenous obliteration of gastric varices with gastro-renal shunt long-term follow-up in 78 patients AJR Am JRoentgenol 20051841340ndash1346

56 Hiraga N Aikata H Takaki S et al The long-term outcome of patients with bleeding gastric varices after balloon-occludedretrograde transvenous obliteration J Gastroenterol 200742663ndash672

57 Akahoshi T Hashizume M Tomikawa M et al Long-term resultsof balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding and risky gastric varices a 10-year experience J Gastroenterol Hepatol 2008231702ndash1709

58 Kumamoto M Toyonaga A Inoue H et al Long-term resultsof balloon-occluded retrograde transvenous obliteration for




gastric fundal varices hepatic deterioration links to portosys-temic shunt syndrome J Gastroenterol Hepatol 2010251129ndash1135

59 Sabri SS Swee W Turba UC et al Bleeding gastric varicesobliteration with balloon-occluded retrograde transvenousobliteration using sodium tetradecyl sulfate foam J Vasc IntervRadiol 201122309ndash316

60 Akahoshi T Tomikawa M Kamori M et al Impact of balloon-

occluded retrograde transvenous obliteration on managementof isolated fundal gastric variceal bleeding Hepatol Res 201242385ndash393

61 Choi SY Won JY Kim KA et al Foam sclerotherapy usingpolidocanol for balloon-occluded retrograde transvenous oblit-eration (BRTO) Eur Radiol 201121122ndash129

62 Clements W Cavanagh K Ali F et al Variant treatment for gastric varices with polidocanol foam using balloon-occludedretrograde transvenous obliteration a pilot study J Med Imag-ing Radiat Oncol 201256599ndash605

63 Saad WE The history and evolution of balloon-occludedretrograde transvenous obliteration (BRTO) from the UnitedStates to Japan and back Semin Intervent Radiol 201128

283ndash28764 Patel A Fischman AM Saad WE Balloon-occluded retrograde

transvenous obliteration of gastric varices AJR Am J Roent-genol 2012199721ndash729

65 Hong CH Kim HJ Park JH et al Treatment of patients withgastric variceal hemorrhage endoscopic N-butyl-2-cyanoacry-late injection versus balloon-occluded retrograde transvenousobliteration J Gastroenterol Hepatol 200924372ndash378

66 Saad WE Sabri SS Balloon-occluded retrograde transvenousobliteration (BRTO) technical results and outcomes SeminIntervent Radiol 201128333ndash338

67 Ninoi T Nakamura K Kaminou T et al TIPS versus trans-catheter sclerotherapy for gastric varices AJR Am J Roentgenol

2004183369ndash

37668 Saad WE Al-Osaimi AM Caldwell SH Pre- and post-balloon-

occluded retrograde transvenous obliteration clinical evalua-tion management and imaging indications managementprotocols and follow-up Tech Vasc Interv Radiol 201215165ndash202

69 Ogawa K Ishikawa S Naritaka Y et al Clinical evaluation of endo-scopic injection sclerotherapy using n-butyl-2-cyanoacrylate for gastric variceal bleedingJ Gastroenterol Hepatol 199914245ndash250

70 Kind R Guglielmi A Rodella L et al Bucrylate treatment of bleeding gastric varices 12 yearsrsquo experience Endoscopy 200032512ndash519

71 Huang YH Yeh HZ Chen GH et al Endoscopic treatment of bleeding gastric varices by N-butyl-2- cyanoacrylate (Histoacryl)

injection long-term ef 1047297cacy and safety Gastrointest Endosc200052160ndash167

72 Akahoshi T Hashizume M Shimabukuro R et al Long-termresults of endoscopic Histoacryl injection sclerotherapy for gastric variceal bleeding a 10-year experience Surgery 2002131(Suppl)S176ndashS181

73 Rengstorff DS Binmoeller KF A pilot study of 2-octyl cyano-acrylate injection for treatment of gastric fundal varices inhumans Gastrointest Endosc 200459553ndash558

74 Mumtaz K Majid S Shah H et al Prevalence of gastric varicesand results of sclerotherapy with N-butyl 2 cyanoacrylate for controlling acute gastric variceal bleeding World J Gastro-enterol 2007131247ndash1251

75 Paik CN Kim SW Lee IS et al The therapeutic effect of cyanoacrylate on gastric variceal bleeding and factors related toclinical outcome J Clin Gastroenterol 200842916ndash922

76 Monsanto P Almeida N Rosa A et al Endoscopic treatment of bleeding gastric varices with histoacryl (N-butyl-2-cyanoacry-late) a South European single center experience Indian JGastroenterol 201232227ndash231

77 Hou MC Lin HC Lee HS et al A randomized trial of endoscopiccyanoacrylate injection for acute gastric variceal bleeding 05 mLversus 10 mL Gastrointest Endosc 200970668ndash675

Reprint requests Address requests for reprints to Juan Carlos Garcia-Pagaacuten MD HepaticHemodynamic Laboratory Liver Unit Hospital Clinic Villarroel 170 08036Barcelona Spain e-mail jcgarciaclinicubes fax 34-93-227-98-56

Con1047298icts of interestThese authors disclose the following Juan Garcia-Pagaacuten received grant sup-port from GORE Andres Cardenas has been a consultant to Limmedx LLCFrontier Medex and BMJ Publishing Group The remaining authors disclose nocon1047298icts




Supplementary Table 1 Studies That Used TIPS or CA in Bleeding GV

First authoryear (reference) Design n


Initialcontrol ( ) Mortality ( )

Any sourceof rebleeding ( )

Follow-up ( mo )

Mahadeva 200323 Cohorts retrospective(GOV1 and GOV2)

43 TIPS (20)vs glue (23)

TIPS (90)vs glue (96)

At 6 monthsTIPS (25) vsglue (15)

At 6 months TIPS (15)vs glue (30)

6

Lo 200743 Randomized prospective(mostly GOV1 andGOV2 and few IGV1)


NA TIPS (30) vsglue (17)

TIPS (43) vs glue (59) 33

Procaccini 200944 Cohorts retrospective(GV type not speci1047297ed)


NA At 1 yearTIPS (33) vsglue (28)

At 1 year TIPS(25) vs glue (10)

TIPS (48)glue (74)

June 2014 Management of Gastric Varices 928e1



GOV2) the incidence of bleeding was 16 36 and

44 at 1 3 and 5 years respectively Size of varices


were directly related with the risk of bleeding (ranging

from an annual incidence of bleeding of 4 in patients

with Child class A with small varices without red signs to

65 in pat ients with Child class C with large varices with

red signs)2 (Figure 2) However these data must be

cautiously interpreted because of the small number of

patients followed for more than 1 year and the unusually

high prevalence (52) of concomitant hepatocelullarcarcinoma The 1-year bleeding risk of the small (n frac14 30)

untreated group of a recent prospective randomized

controlled trial (RCT) comparing cyanoacrylate (CA)

(n frac14 30) vs beta-blockers (n frac14 29) was around 103

Variceal size and liver function evaluated by the Model

for End-Stage Liver Disease score were again factors

associated with a high risk of bleeding In this study GV

were mainly GOV2 with few IGV1 There were signi1047297cant

differences in favor of CA for the prevention of bleeding

and survival when compared with no treatment and only

for prevention of rebleeding when compared with pro-

pranolol However larger studies are needed before a

formal recommendation in regard to the need and typeof primary prophylaxis for GV can be made Until then

our recommendation is not to use primary prophylaxis in

GV or alternatively use nonselective beta-blockers

Management of Acute Gastric VaricealBleeding

Although no studies have been speci1047297cally devoted to

address this issue in patients with cardiofundal varices

general consensus is that the initial management is

similar to that of esophageal variceal bleeding including

the use of prophylactic antibiotics careful replacement of

volemia with a restrictive transfusion policy and the

early administration of vasoactive drugs (terlipressin

somatostatin or a somatostatin analogue)45 IGV1

varices which often appear as a consequence of large

spontaneous splenorenal shunts may bleed with portal

pressure gradients lower than those needed for

esophageal varices It can then be hypothesized that

more powerful vasoconstrictors are needed not only

to decrease portal pressure but also to markedly

reduce portal and collateral blood 1047298ow to control acute

cardiofundal variceal bleeding In our experience

nearly 40 of patients with bleeding IGV1 who wereonly receiving vasoactive drugs require rescue therapy

mainly transjugular intrahepatic portosyst emic shunt

(TIPS) to achieve 5-day control of bleeding6 Therefore

we currently do not recommend using vasoactive drugs

alone but always with concomitant endoscopic therapy

Speci1047297c high-quality data on the use of endoscopic

therapy for acute GV bleeding are limited and in most

published RCTs only half of patients included in the trials

had cardiofundal varices Despite these limitations most

uncontrolled series report a high rate of control of

bleeding with the use of tissue adhesives such as CA

(gt

90) (Table 1) In addition small-size RCTs comparingtissue adhesives vs either endoscopic band ligation (EBL)

or endoscopic injection sclerot herapy (EIS) have shown

that tissue adhesives are equally7 or more89 effective than

EBL in the control of acute bleeding and more effective

than both in preventing rebleeding In addition tissue

adhesives perform better than sclerotherapy in

achieving initial hemostasis910 GOV1 varices are usually

treated as esophageal varices with EBL although some

investigators also recommend the use of tissue

adhesives for GOV1 varices11 Overall experts agree that

endoscopic therapy with tissue adhesives mainly CA is

the therapy of choice for acute bleeding from IGV1 and

GOV241213 If tissue adhesive is not available band

Figure 1 Sarinrsquos classi1047297cation of GV Modi1047297ed with permis-sion from the American Gastroenterological Association(AGA) Institute Gastroslides ndash Cirrhosis and PortalHypertension

Figure 2 A large gastric varix (IGV1) with a recent nipple sign































bleeding












Lintonndash


















to treatment)



( mo )




glue (23)93 (90 vs 96) 20 (25 vs 15) 6




glue (29)81 (50 vs 88) 53 (67 vs 38) mdash


glue (9)59 (38 vs 78) 18 (25 vs 11) 16


93 (93 vs 93) 64 (63 vs 65) 36


88 NR mdash













mm Hg

















studied further











































































rebleeding















Thrombin












range from 7ndash

5036ndash41






recommended



























Surgery









are scarce





by Kanagawa et al

45










Al-Osaimi et al49




























































































Summary






















































































































2004183369ndash























Follow-up ( mo )






6









TIPS (48)glue (74)































bleeding












Lintonndash


















to treatment)



( mo )




glue (23)93 (90 vs 96) 20 (25 vs 15) 6




glue (29)81 (50 vs 88) 53 (67 vs 38) mdash


glue (9)59 (38 vs 78) 18 (25 vs 11) 16


93 (93 vs 93) 64 (63 vs 65) 36


88 NR mdash













mm Hg

















studied further











































































rebleeding















Thrombin












range from 7ndash

5036ndash41






recommended



























Surgery









are scarce





by Kanagawa et al

45










Al-Osaimi et al49




























































































Summary






















































































































2004183369ndash























Follow-up ( mo )






6









TIPS (48)glue (74)












mm Hg

















studied further











































































rebleeding















Thrombin












range from 7ndash

5036ndash41






recommended



























Surgery









are scarce





by Kanagawa et al

45










Al-Osaimi et al49




























































































Summary






















































































































2004183369ndash























Follow-up ( mo )






6









TIPS (48)glue (74)














rebleeding















Thrombin












range from 7ndash

5036ndash41






recommended



























Surgery









are scarce





by Kanagawa et al

45










Al-Osaimi et al49




























































































Summary






















































































































2004183369ndash























Follow-up ( mo )






6









TIPS (48)glue (74)

























































































Summary






















































































































2004183369ndash























Follow-up ( mo )






6









TIPS (48)glue (74)




























































2004183369ndash























Follow-up ( mo )






6









TIPS (48)glue (74)









Follow-up ( mo )






6









TIPS (48)glue (74)


2014 06 manejo de las varices gastricas

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