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

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.

Informations de copyright

Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.

Déclaration de conflit d'intérêts

Disclosure The following authors disclosed financial relationships: G. Trikudanathan: Consultant for Boston Scientific Corporation. A. Bhatt: Consultant for Medtronic, Inc, US Endoscopy, Olympus Corporation, and Intuitive Surgical Inc; patent-holder for a commercial device licensed to Medtronic, Inc. V. Chandrasekhara: Consultant for Covidien LP and Boston Scientific Corporation; research support from Microtech Endoscopy; shareholder with Nevakar, Inc. A. Kahn: Consultant for MiMedx. K. Krishnan: Consultant for Boston Scientific Corporation and Olympus Corporation of the Americas. N. A. Kumta: Consultant for Apollo Endosurgery US Inc, Boston Scientific Corporation, Safeheal, and Olympus Corporation of the Americas. D. R. Lichtenstein: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; speaker for Olympus Corporation of the Americas and Boston Scientific Corporation; Clinical Events Committee for Boston Scientific Corporation (chair) and SafeHeal; advisory board and research committee for Iterative Health; GI boards committee for the American Board of Internal Medicine. J. V. Obando: Shareholder with Surgenly LLC. R. Pannala: Consultant for HCL Technologies; scientific advisory board for Bluestar Genomics and Nestle HealthCare Nutrition Inc; research support from Erbe USA Inc; Medical Director (AZ Chapter) for the National Pancreas Foundation. M. Saumoy: Consultant for Becton, Dickinson and Company and Intuitive Surgical, Inc. A. J. Trindade: Consultant for Pentax of America, Inc, Boston Scientific Corporation, Lucid Diagnostics, and Exact Science. J. Yang: Consultant for Cook Medical, Interscope, and Steris. R. J. Law: Consultant for Conmed Corporation, Boston Scientific Corporation, Olympus America Inc, and Medtronic USA Inc; royalties from UpToDate. All other authors disclosed no financial relationships.