Gastric variceal
bleeding can be challenging to the clinician.
Tissue adhesives can control acute
bleeding in over 80%, with rebleeding rates of 20-30%, and should be first-line
therapy where available. Endoscopic ultrasound can assist in better eradication of
varices. The potential risks of damage to equipment and embolic phenomena can be minimized with careful attention to technique. Variceal band
ligation is an alternative to
tissue adhesives for the management of acute
bleeding, but not for
secondary prevention due to a higher rate of rebleeding. Endoscopic
therapy with human
thrombin appears promising, with initial haemostasis rates typically over 90%. The lack of controlled studies for
thrombin prevents universal recommendation outside of clinical trials. Balloon occluded retrograde transvenous obliteration is a recent technique for patients with gastrorenal shunts, although its use is limited to clinical trials. Transjugular intrahepatic portosystemic
stent shunt is an option for refractory
bleeding and secondary prophylaxis, with uncontrolled studies demonstrating initial haemostasis obtained in over 90%, and rebleeding rates of 15-30%. Non-cardioselective beta-blockers are an alternative to transjugular intrahepatic portosystemic
stent shunt for secondary prophylaxis, although the evidence is limited. Shunt surgery should be considered in well-compensated patients.
Splenectomy or embolization is an option in patients with
segmental portal hypertension.