Difference between type 2 gastroesophageal varices and isolated fundic varices in clinical profiles and portosystemic collaterals

Abstract

Background: There is significant heterogeneity between gastroesophageal varices (GOV2) and isolated gastric varices (IGV1). The data on the difference between GOV2 and IGV1 are limited.

Aim: To determine the etiology, clinical profiles, endoscopic findings, imaging signs, portosystemic collaterals in patients with GOV2 and IGV1.

Methods: Medical records of 252 patients with gastric fundal varices were retrospectively collected, and computed tomography images were analyzed.

Results: Significant differences in routine blood examination, Child-Pugh classification and MELD scores were found between GOV2 and IGV1. The incidence of peptic ulcers in patients with IGV1 (26.55%) was higher than that of GOV2 (11.01%), while portal hypertensive gastropathy was more commonly found in patients with GOV2 (22.02%) than in those with IGV1 (3.54%). Typical radiological signs of cirrhotic liver were more commonly observed in patients with GOV2 than in those with IGV1. In patients with GOV2, the main afferent vessels were via the left gastric vein (LGV) (97.94%) and short gastric vein (SGV) (39.18%). In patients with IGV1, the main afferent vessels were via the LGV (75.61%), SGV (63.41%) and posterior gastric vein (PGV) (43.90%). In IGV1 patients with pancreatic diseases, spleno-gastromental-superior mesenteric shunt (48.15%) was a major collateral vessel. In patients with fundic varices, the sizes of gastric/esophageal varices were positively correlated with afferent vessels (LGVs and PGVs) and efferent vessels (gastrorenal shunts). The size of the esophageal varices was negatively correlated with gastrorenal shunts in GOV2 patients.

Conclusion: Significant heterogeneity in the etiology and vascular changes between GOV2 and IGV1 is useful in making therapeutic decisions.

Keywords: Gastrorenal shunt; Liver cirrhosis; Pancreatic diseases; Spleno-gastroomental-superior mesenteric shunt.

Figure 1

Flowchart of the patients’ enrollment. GOV2: Gastroesophageal varices; IGV1: Isolated gastric varices; TIPS: Transjugular intrahepatic portosystemic shunt; BRTO: Balloon-occluded retrograde transvenous obliteration; EVL: Endoscopic variceal ligation; EIS: Endoscopic injection sclerosis; ECGI: Endoscopic cyanoacrylate glue injection.

Figure 2

Computed tomography portal venography of gastric variceal collateral vessels. A: Coronal oblique volume-rendered (VR) computed tomography (CT) portal venogram views (A1) and schematic drawing (A2) illustrated collateral circulation of esophageal varices (GVs) in the patient with gastroesophageal varices (75-years-old male patients with liver cirrhosis). GVs were supplied by left gastric vein (LGV) (arrowhead) and SGV, and drained by gastrocaval shunt (GCS), and esophageal and para-esophageal varices (EVs); B: Coronal oblique VR CT portal venogram views (B1) and schematic drawing (B2) illustrated collateral circulation of GVs in the patient with isolated gastric varices (IGV1) (75-years-old female patients). GVs were supplied by LGV (arrowhead) and SGV (white arrow), and drained by GRS, SRS and intrahepatic portosystemic shunts (black arrow in the MIP image); C: Coronal oblique cinematically rendered reconstruction in CT portal venogram views (C1) and schematic drawing (C2) showing collateral vessels in a 42-years-old male patient with IGV1 caused by pancreatic pseudocyst secondary to pancreatitis. GVs were supplied by SGV (arrowhead), spleno-gastroomental -superior mesenteric shunt (white arrow) was a major collateral vessel due to partial splenic vein occlusion (thick arrow).

Figure 3

treatment algorithm for gastric fundic varices. ¹Gastro-renal shunt or gastrocaval shunt occurred frequently in gastroesophageal varices patients with small size of esophageal varices; ²Gastro-renal shunt or gastrocaval shunt were mainly found in isolated gastric varices patients caused by liver cirrhosis; ³Endo-scopic injection sclerosis should be performed when the size of esophageal varices is larger than 2 cm; ⁴Balloon-occluded retrograde transvenous obliteration should be considered in the patients with large gastrorenal shunts or gastrocaval shunt. GOV2: Gastroesophageal varices; IGV1: Isolated gastric varices; EVL: Endoscopic variceal ligation; EV: Esophageal varices; ECGI: Endoscopic cyanoacrylate glue injection; GV: Gastric varices; TIPS: Transjugular intrahepatic portosystemic shunt; EUS: Endoscopic ultrasound; EIS: Endoscopic injection sclerosis; BRTO: Balloon-occluded retrograde transvenous obliteration.