The Liver Unit and Monarch Liver Laboratory, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India.
Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India.
BMC Gastroenterol. 2020 Oct 30;20(1):361. doi: 10.1186/s12876-020-01513-7.
Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes. Conventionally, gastric varices have been described based on the location and extent and endoscopic treatments offered based on these descriptions. With improved understanding of portal hypertension and the dynamic physiology of collateral circulation, gastric variceal classification has been refined to include inflow and outflow based hemodynamic pathways. These have led to an improvement in the management of gastric variceal disease through newer modalities of treatment such as endoscopic ultrasound-guided glue-coiling combination therapy and the emergence of highly effective endovascular treatments such as shunt and variceal complex embolization with or without transjugular intrahepatic portosystemic shunt (TIPS) placement in patients who are deemed 'difficult' to manage the traditional way. Furthermore, the decisions regarding TIPS and additional endovascular procedures in patients with gastric variceal bleeding have changed after the emergence of 'portal hypertension theories' of proximity, throughput, and recruitment. The hemodynamic classification, grounded on novel theories and its cognizance, can help in identifying patients at baseline, in whom conventional treatment could fail. In this exhaustive review, we discuss the conventional and hemodynamic diagnosis of gastric varices concerning new classifications; explore and illustrate new 'portal hypertension theories' of gastric variceal disease and corresponding management and shed light on current evidence-based treatments through a 'new' algorithmic approach, established on hemodynamic physiology of gastric varices.
胃静脉曲张比食管静脉曲张少见。然而，胃静脉曲张出血更严重，预后更差。传统上，根据位置和范围描述胃静脉曲张，并根据这些描述提供内镜治疗。随着对门脉高压和侧支循环动态生理学认识的提高，胃静脉曲张的分类已得到改进，包括基于血流动力学途径的流入和流出。这些新的治疗方式如内镜超声引导下胶圈联合治疗以及分流和静脉曲张复合栓塞等高度有效的血管内治疗的出现，改善了胃静脉曲张疾病的管理，即使对于传统治疗方式认为“困难”的患者也是如此。此外，在出现“门脉高压接近、吞吐量和招募理论”后，关于胃静脉曲张出血患者的 TIPS 和其他血管内手术的决策发生了变化。基于新理论及其认知的血流动力学分类有助于在基线时识别可能常规治疗失败的患者。在这篇全面的综述中，我们讨论了传统和血流动力学诊断胃静脉曲张的新分类；探讨和阐明了胃静脉曲张疾病的新“门脉高压理论”及其相应的管理，并通过基于胃静脉曲张血流动力学生理学的“新”算法方法阐明了当前基于证据的治疗方法。
