-Review-

Treatment Modalities for Bleeding Esophagogastric Varices

Hiroshi Yoshida^1,2, Yasuhiro Mamada¹, Nobuhiko Taniai¹, Masato Yoshioka¹, Atsushi Hirakata^1,2, Youichi Kawano¹, Yoshiaki Mizuguchi¹, Tetsuya Shimizu¹, Junji Ueda¹ and Eiji Uchida¹

¹Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
²Department of Surgery, Nippon Medical School Tama Nagayama Hospital

Bleeding from esophageal varices (EVs) or gastric varices (GVs) is a catastrophic complication of chronic liver disease. In this paper, we review the management of bleeding EVs and GVs.
Diagnosis of EVs and GVs: The grading system for esophagogastric varices proposed by the Japan Society for Portal Hypertension classifies GVs into those involving the cardia (Lg-c), the fundus (Lg-f), and both the cardia and the fundus (Lg-cf). In this review, we divide GVs into 2 categories: Lg-c (cardiac varices: CVs) and Lg-cf or Lg-f (fundal varices: FVs).
Treatment Modalities for EVs and GVs: Treatment modalities for EVs and GVs include placement of a Sengstaken-Blakemore tube, pharmacologic therapy, surgery, interventional radiology, and endoscopic treatment.
Management of Bleeding EVs and GVs: In Japan, endoscopic treatment has recently become the therapy of choice for bleeding EVs or GVs. In other countries, especially the United States, vasoactive drugs and endoscopic treatment are routinely used to manage variceal hemorrhage.
Bleeding EVs: Endoscopic variceal ligation is useful for controlling bleeding from EVs. However, confirmation of ligation precisely at the site of bleeding is usually difficult in patients with massive variceal bleeding. The site of acute bleeding can generally be identified by means of water instillation and suction. Ligation is then performed at the bleeding point. If endoscopic hemostasis is unsuccessful, a Sengstaken-Blakemore tube is used as a temporary bridge to other treatments. Transportal obliteration is useful for blocking variceal blood flow.
Bleeding GVs: Endoscopic injection sclerotherapy with a tissue adhesive, such as N-butyl-cyanoacrylate or isobutyl-2-cyanoacrylate, is effective for acute bleeding from GVs. However, bleeding from the GV injection site and rebleeding from the rupture point have been reported in patients receiving endoscopic injection sclerotherapy. If endoscopic hemostasis is unsuccessful, a Sengstaken-Blakemore tube is used as a temporary bridge to other treatments. Balloon-occluded retrograde transvenous obliteration and transportal obliteration are useful for the treatment of uncontrolled bleeding from GVs.
Prevention of Recurrent Variceal Hemorrhage: Given the high recurrence rate, survivors of an acute variceal hemorrhage should receive treatment to prevent recurrence. Complete eradication of EVs or GVs and maintenance of low portal venous pressure are essential for preventing recurrence of variceal hemorrhage.

J Nippon Med Sch 2012; 79: 19-30

Keywords
esophageal varices, gastric varices, bleeding, surgery, interventional radiology, embolization, endoscopic treatment

Correspondence to
Hiroshi Yoshida, MD, Department of Surgery, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama, Tokyo 206-8512, Japan
hiroshiy@nms.ac.jp

Received, August 27, 2011
Accepted, October 31, 2011