Current Approaches to the Treatment of Gastric Varices: Glue, Coil Application, TIPS, and BRTO

Gastric varices are less common than esophageal varices, and their treatment is quite challenging. Gastric varix bleedings (GVB) occur less frequently than esophageal varix (EV) bleedings and represent 10% to 30% of all variceal bleedings. They are; however, more severe and are associated with high mortality. Re-bleeding may occur in 35% to 90% of cases after spontaneous hemostasis. GV bleedings represent a serious clinical problem compared with esophageal varices due to their location. Sclerotherapy and band ligation, in particular, are less effective. Based on the anatomic site and location, treatment differs from EV and is categorized into two groups (i.e., endoscopic or radiologic treatment). Surgical management is used less frequently. Balloon-occluded retrograde transvenous obliteration (BRTO) and cyanoacrylate are safe but there is a high risk of re-bleeding. Portal pressure elevates following BRTO and leads to worsening of esophageal varix pressure. Other significant complications may include hemoglobinuria, abdominal pain, fever, and pleural effusion. Shock and atrial fibrillation are major complications. New and efficient treatment modalities will be possible in the future.

Ultrasound system to measure esophageal varix pressure: an in vitro validation study

We report our experience with an ultrasound system to measure esophageal varix pressure in an in vitro model. The ultrasound system consists of a 12.5 MHz frequency intraluminal ultrasound probe, a water infusion catheter, and a manometry catheter, all contained within a nondistensible latex bag. Esophagi and external jugular veins were harvested from five pigs. The vein and ultrasound system were placed inside the esophagus. One end of the vein was connected to a water reservoir to modulate its pressure; the other end was connected in two different ways to simulate hydrodynamic and hydrostatic flow conditions. The bag was inflated with water until vein occlusion was discernible on the ultrasound images. The influences of vein pressure, vein cross-sectional area and esophageal elasticity on the ultrasound measurement of vein pressure were assessed. A total of 108 trials were performed at nine different vein pressures. Complete vein occlusion occurred when the bag pressure was slightly greater (1.4 ± 0.7 mmHg) than the vein pressure. For a vein pressure of 25 mmHg, the average occlusion and opening pressures were 27 ± 0.2 and 25.7 ± 0.3 mmHg, respectively ( P < .05) suggesting that the vein opening pressure on the ultrasound images is more accurate than the vein closing pressure. In conclusion, the ultrasound technique can accurately measure intravariceal pressure in vitro. The bag pressure at the point of vein reopening is the best determinant of the vein pressure.