Cost-Effective Therapeutic Strategy for the Management of Bleeding Gastric Fundal Varices

 

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We read with great interest the article by Kok et al. on a case of bleeding gastric fundal varices with a fatal outcome [1].

The most widely used classification of gastric varices is that proposed by Sarin and Kumar [2]. Concomitant esophageal varices were eradicated by endoscopic band ligation, so the treated gastric varices appear to have been isolated fundal varices, which are IGV1 in the Sarin and Kumar classification [2]. Because most fundal varices are associated with a gastrorenal shunt, blood flow is more abundant and rapid than with other types of gastric varices [3]. Although cyanoacrylate is highly effective for controlling acute bleeding from fundal varices, its value in fundal varices without active bleeding is controversial [4]. The authors used a 1 : 3 mixture of cyanoacrylate and Lipiodol for elective therapy after achieving initial hemostasis with a 1 : 1 mixture. However, when the volume injected and the dilution of cyanoacrylate are increased, polymerization is delayed and the risk of systemic complications related to embolization is increased. Diffuse fundal varices are likely to be more difficult to obliterate than localized fundal varices, due to their structural complexity [5] and rapid blood flow [6]. Obliterating the afferent veins in fundal varices is important in order to prevent recurrent bleeding [4]. Irisawa et al. proposed that the ratio of cyanoacrylate to Lipiodol should be increased to more than 62.5 %, or that another treatment method should be selected if the diameter of fundal varices is over 12 mm [7]. We have experienced leakage of cyanoacrylate into a draining vein (gastrorenal shunt) after undiluted cyanoacrylate was injected into fundal varices with a maximum diameter of 13 mm [8]. Although the authors chose transjugular intrahepatic portosystemic shunting (TIPS) to manage uncontrollable rebleeding from the varices, TIPS often fails to prevent recurrent bleeding from fundal varices with a well-developed gastrorenal shunt unless coil embolization is also performed [9] [10].

However, coil embolization is expensive. Since the fundal varices were associated with a gastrorenal shunt, we believe that the most appropriate treatment in the patient concerned might have been initial hemostasis with cyanoacrylate, followed by balloon-occluded retrograde transvenous obliteration (B-RTO) [11], which is less invasive than TIPS. After initial hemostasis is achieved, with or without cyanoacrylate, multidetector-row computed tomographic angiography [12] should be carried out to confirm the existence of a gastrorenal shunt and to assess the indications for B-RTO (Figures [1], [2]).

Figure 1 Multidetector-row computed tomographic angiogram before elective treatment of gastric fundal varices. The varices (small white arrow), feeding vein (large white arrow), and gastrorenal shunt (black arrow) are indicated.

Figure 2 Balloon-occluded retrograde transvenous obliteration. The varices and the afferent vein and gastrorenal shunt were obliterated using ethanolamine oleate.

References

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A. Matsumoto, M. D.

Dept. of Gastroenterology, Takeda General Hospital

28-1, Ishida Moriminami-cho, Fushimi-ku
Kyoto 601-1495
Japan

Fax: +81-75-571-8877

Email: marsh@hkg.odn.ne.jp