Therapeutic Gastrointestinal Endoscopy

Bleeding from esophageal and gastric varices is the most life-threatening complication of liver cirrhosis and portal hypertension. In gastric variceal bleeding, endoscopic management by injection of cyanoacrylate may be more effective than endoscopic ligation. Endoscopic injection of cyanoacrylate is a safe and effective hemostatic method for patients with gastric variceal bleeding. Repeat endoscopic treatment is less effective than the initial injection. Advanced-stage cirrhosis and hepatocellular carcinoma are major risk factors for failed hemostasis after cyanoacrylate injection of gastric varices. 2.1 General Information Bleeding from esophageal (EVs) and gastric varices (GVs) is the most life-threatening complication of liver cirrhosis and portal hypertension. GVs are less common than EVs, occurring in 20% of patients with portal hypertension. GVs bleed less frequently but more severely than EVs. Unlike EVs, GV bleeding is complicated to control by routine band ligation, because it is difficult to have retroflex position of the scope to reach GVs. Furthermore, GVs are often associated with large draining splenorenal shunts that complicate the condition and contribute to hepatic encephalopathy. Once gastric fundal varices bleed, the mortality rate ranges from 25% to 55%. Patients with GV bleeding also have a higher risk of re-bleeding and a decreased rate of survival [1]. 2.2 Classification 2.2.1 Classification of Gastric Varices Proposed by Sarin et al. [2] Sarin’s classification is useful for considering the management of gastric varices. According to anatomical continuation with esophageal varices and their location, diagnosis is made. When the gastroesophageal varices (GOV) are an extension of esophageal varices, they are categorized into two types. The most common are Type 1 gastroesophageal varices (GOV1), which extend along the lesser curvature (Fig. 2.1). They are considered extensions of esophageal varices, and the recommended management is the same as that of esophageal varices. Type 2 gastroesophageal varices (GOV2) extend along the fundus. They tend to be longer and more tortuous than Type 1 gastric varices (Fig. 2.2). Isolated gastric varices (IGV) occur in the absence of esophageal varices and are also classified into two types. Type 1 (IGV1) are located in the fundus and tend to be tortuous and complex (Fig. 2.3), and Type 2 (IGV2) are located in the body and antrum or around the pylorus (Fig. 2.4). What You Should Know Here: Classification proposed by Sarin et al. [2] Gastroesophageal varices (GOV)—gastric varices in continuity with esophageal varices • GOV1—along the lesser curvature (usually 2–5 cm in length). • GOV2—along the greater curvature extending towards the gastric fundus. Isolated gasric varices (IGV) • IGV1—isolated cluster of gastric varices in the gastric fundus. • IGV2—isolated gastric varices in other parts of the stomach (body/antrum). 2 W. C. Chung (*) Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea e-mail: jwchulkr@catholic.ac.kr