Management of gastric variceal hemorrhage

Gastric varices represent an inhomogeneous entity morphologically, topographically and hemodynamically. Hence proper classification is mandatory not only to prognosticate but also to determine optimal therapeutic option. Although a number of classifications based on variceal location, morphology and color have been proposed, the one proposed by Sarin et al2 is most widely used and has been recommended for use by the Baveno consensus working group. The classification takes into account location of varices in the stomach and their relation to esophageal varices. Varices are thus classified into 2 broad categories: gastro-esophageal varices (GOV) when they extend from the esophagus into the stomach and isolated gastric varices (IGV) when gastric varices are present in absence of esophageal varices. GOV are further sub-classified into GOV1 (extending along the lesser curvature of the stomach) and GOV2 (extending along the greater curvature towards the gastric fundus). Similarly IGV have been sub-classified as IGV1 (located in the gastric fundus) and IGV2 (located in the gastric antrum, corpus or pylorus). GOV1 is the commonest variant, accounting for 74% of all gastric varices, while GOV2, IGV1 and IGV2 constitute 16%, 8% and 2%, respectively. The risk of bleeding is greater with fundal varices (IGV1 78% and GOV2 55%) than with GOV1 and IGV2 (10%).1 Although gastric varices bleed less often than esophageal varices, gastric variceal hemorrhage is more severe, translating into higher transfusion re­ quirements as well as mortality, and has higher inci­ dence of rebleed.1,3 Moreover, on account of higher prevalence of spontaneous gastro-renal shunts, gas­ tric varices can bleed at porta-systemic pressure gradient <12 mmHg4 and have higher incidence of encephalopathy.5 Risk factors for gastric variceal bleed include fundal location, large size, red color sign and advanced Child stage.6 Gastric varices should be implicated as the source of bleeding if there is active spurt or ooze, adherent clot, presence of large gas-