Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.
Diagnostic Imaging Center, Hospital Clinic, Barcelona, Spain.
Clin Gastroenterol Hepatol. 2014 Jun;12(6):919-28.e1; quiz e51-2. doi: 10.1016/j.cgh.2013.07.015. Epub 2013 Jul 27.
According to their location, gastric varices (GV) are classified as gastroesophageal varices and isolated gastric varices. This review will mainly focus on those GV located in the fundus of the stomach (isolated gastric varices 1 and gastroesophageal varices 2). The 1-year risk of GV bleeding has been reported to be around 10%-16%. Size of GV, presence of red signs, and the degree of liver dysfunction are independent predictors of bleeding. Limited data suggest that tissue adhesives, mainly cyanoacrylate (CA), may be effective and better than propranolol in preventing bleeding from GV. General management of acute GV bleeding must be similar to that of esophageal variceal bleeding, including prophylactic antibiotics, a careful replacement of volemia, and early administration of vasoactive drugs. Small sample-sized randomized controlled trials have shown that tissue adhesives are the therapy of choice for acute GV bleeding. In treatment failures, transjugular intrahepatic portosystemic shunt (TIPS) is considered the treatment of choice. After initial hemostasis, repeated sessions with CA injections along with nonselective beta-blockers are recommended as secondary prophylaxis; whether CA is superior to TIPS in this scenario is not completely clear. Balloon-occluded retrograde transvenous obliteration (BRTO) has been introduced as a new method to treat GV. BRTO is also effective and has the potential benefit of increasing portal hepatic blood flow and therefore may be an alternative for patients who may not tolerate TIPS. However, BRTO obliterates spontaneous portosystemic shunts, potentially aggravating portal hypertension and its related complications. The role of BRTO in the management of acute GV bleeding is promising but merits further evaluation.
根据其位置，胃静脉曲张（GV）分为胃食管静脉曲张和孤立性胃静脉曲张。本综述将主要关注位于胃底部的胃静脉曲张（孤立性胃静脉曲张 1 和胃食管静脉曲张 2）。据报道，GV 出血的 1 年风险约为 10%-16%。GV 的大小、红色征的存在和肝功能障碍的程度是出血的独立预测因素。有限的数据表明，组织粘合剂，主要是氰基丙烯酸酯（CA），在预防 GV 出血方面可能比普萘洛尔更有效。急性 GV 出血的一般管理必须与食管静脉曲张出血相似，包括预防性使用抗生素、仔细补充血容量和早期使用血管活性药物。小型随机对照试验表明，组织粘合剂是急性 GV 出血的首选治疗方法。在治疗失败的情况下，经颈静脉肝内门体分流术（TIPS）被认为是首选治疗方法。在初次止血后，建议重复使用 CA 注射联合非选择性β受体阻滞剂作为二级预防；CA 在这种情况下是否优于 TIPS 尚不完全清楚。球囊阻塞逆行经静脉闭塞术（BRTO）已被引入治疗 GV 的一种新方法。BRTO 也是有效的，并且具有增加门静脉血流的潜在益处，因此可能是那些可能无法耐受 TIPS 的患者的替代方法。然而，BRTO 会闭塞自发性门体分流，可能会加重门静脉高压及其相关并发症。BRTO 在急性 GV 出血管理中的作用很有前景，但值得进一步评估。
