Portal Hypertensive Gastropathy and Gastric Varices
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Direct answer
Portal hypertensive gastropathy is a diffuse mucosal change of the stomach caused by raised portal pressure, showing a mosaic or snakeskin pattern. Gastric varices are dilated submucosal veins that bleed more severely and need different treatment. Bleeding fundal varices are usually sealed with cyanoacrylate glue, with BRTO as an alternative, while non-selective beta blockers form the drug treatment of the gastropathy.
What you must remember
- Mosaic mucosa: the snakeskin pattern of pink polygonal areas separated by a whitish-yellow border is the endoscopic hallmark of portal hypertensive gastropathy.
- Sarin classification: GOV1 and GOV2 extend from the oesophagus, while IGV1 (fundal) and IGV2 (body or antrum) are isolated gastric varices.
- Cyanoacrylate glue: N-butyl-2-cyanoacrylate polymerises on contact with blood and is the standard endoscopic option for GOV2 and IGV1.
- BRTO: balloon-occluded retrograde transvenous obliteration blocks the gastrorenal shunt with a balloon and injects sclerosant retrograde into the varix.
- Beta blockers: propranolol or nadolol lower portal pressure and form the basis of drug treatment in portal hypertensive gastropathy.
- Gastric variceal bleeding: tends to be more severe than oesophageal variceal bleeding, and bands do not hold fundal varices well.
- Glue embolism: the feared complication of cyanoacrylate is embolisation to the lungs or the systemic circulation.
- Acute bleeding: octreotide is started with antibiotic prophylaxis and endoscopic therapy, as for any variceal bleed.
Choosing therapy by the Sarin type
Gastric varices are not managed alike, because the route of drainage decides the approach. The Sarin classification sorts them by anatomy, and CT or MR angiography maps the drainage route before treatment is chosen. The table links each type to its usual first option in a bleeding patient.
| Sarin type | Anatomical extent | Usual first option |
|---|---|---|
| GOV1 | Extends from the oesophagus along the lesser curvature | Band ligation |
| GOV2 | Extends along the greater curvature into the fundus | Cyanoacrylate injection |
| IGV1 | Isolated fundal varix | Cyanoacrylate injection |
| IGV2 | Isolated varix in the body or antrum | Individualised, often glue or shunt based |
GOV1 behaves much like an oesophageal varix, so banding is a reasonable first step. Fundal varices, whether GOV2 or IGV1, are poorly held by bands, which is why glue is preferred for them. Glue must be injected in small, controlled amounts because embolisation is the feared complication. When glue fails or a large gastrorenal shunt feeds the varix, BRTO or TIPS is considered.
Where the exam tries to catch you
Examiners test whether you can tell a diffuse mucosal disease from a discrete bleeding varix.
- Trap: banding a mosaic stomach as if it were a bleeding varix Correct: portal hypertensive gastropathy is diffuse and is treated by lowering portal pressure with beta blockers, not by ligation.
- Trap: banding a fundal varix as if it were oesophageal Correct: bands do not hold fundal varices well, so cyanoacrylate is the usual choice for GOV2 and IGV1.
- Trap: calling every gastric varix GOV Correct: IGV1 and IGV2 are isolated gastric varices without an oesophageal component, so the Sarin label changes the plan.
Frequently asked questions
Which endoscopic finding characterises portal hypertensive gastropathy?
Portal hypertensive gastropathy is characterised by a mosaic or snakeskin mucosal pattern, often with red spots, mainly in the body and fundus of the stomach. The pattern is diffuse rather than a discrete lesion, and it is the endoscopic clue that portal pressure is raised.
What classification is used for gastric varices and why does it matter?
The Sarin classification divides gastric varices into GOV1, GOV2, IGV1 and IGV2 according to their anatomical extent. It matters because the type predicts treatment, with cyanoacrylate glue injection favoured for GOV2 and isolated fundal varices (IGV1).
What is BRTO and when is it used for gastric varices?
Balloon-occluded retrograde transvenous obliteration is a radiological procedure in which a balloon catheter occludes the gastrorenal shunt while sclerosant is injected retrograde into the varix. It is used for gastric varices fed by a large gastrorenal shunt, and it is considered when glue injection is not suitable.
Why is cyanoacrylate glue injection hazardous?
Cyanoacrylate polymerises on contact with blood, which seals the varix, but the glue can also embolise to the lungs or the systemic circulation. Operators therefore inject it in small, controlled amounts under endoscopic vision.
Do non-selective beta blockers treat portal hypertensive gastropathy?
Non-selective beta blockers such as propranolol or nadolol lower portal pressure in portal hypertensive gastropathy and form the mainstay of drug therapy. Refractory bleeding is managed with other measures, including TIPS in selected patients.