Thank you, cheers, and it's a great opportunity because it is three decades, 30 years of declassification for gastric viruses. I bring greetings from the Institute of Liver and Biliary Sciences, which is a dedicated liver university. I have nothing to disclose, except that we have very bright and young faculty and brighter residents who support us. Gastric viruses are common in portal hypertension, maybe one in five, more common in bleeders than non-bleeders, and more common in non-sterotics, especially portal vein thrombosis. The risk of bleeding depends on the type of gastric viruses, the frequency, the severity, and the influence of esophageal viruses on gastric viruses. I'll go through some of these slowly. The viruses from esophagus which extend to the lesser curve are GOV1, which are present in 70 percent of the patients with portal hypertension, and those which are on the greater curve are GOV2. Those which are isolated, you can see a gap of about a centimeter or so. These are isolated gastric viruses present in about seven percent. Then you have the diurnal viruses or ectopic viruses in the incisura or entrum. The bleeding from these viruses are differently placed. You see GOV1 only 12 percent bleed, while GOV2, half of them bleed. IGV1, though less common, bleed in about four out of five, and IGV2 bleed in about six percent or so. It's important to have some of the venous anatomy of these viruses clearly understood. The viruses which are from the spleen and go through the splenic vein, will give you short gastric veins. Those which are on the lesser curve will be the left gastroepiploic vein, the coronary vein, and the posterior gastric vein. These are our different sites of formation. The posterior gastric, when you see some varics here, when you see a varics on the other side, or on the lesser curve side. I'll show you some of the CT pictures for you to remember. On the left of the stomach, means towards the midline, you will have the varics which are lesser curve, they would be left gastric vein. Then you have varics which are coming on the other side of the stomach, the short gastric vein, and in the middle, which will be the posterior gastric vein. So these are the efferents. Then you will have efferents which will come out. So the paraisophageal varices, or the gastric varices, this is efferent path 1. And the other varices can be gastro renal, left renal, or the IVC. This is the efferent path 2. How are we going to predict bleeding from gastric varices? This is first bleed. These patients have never bled. You can see large gastric varics. Now what is large? Very simply, you have the endoscope, which is about 10 millimeter. If it is more than that, it is large, and if it is two times that, it is really high risk. This is again large gastric varics, which has not bled, but it can show you the red color signs. Here you see a bunch of varices which are seen here, much larger with RCS, and this is again a large gastric varics. So several years ago, people from Korea as well as our group showed, what are the predictors? So if the size is more than 20 millimeter, if the MELD is more than 17 or equal to that, and if the portal hypertensive gastropathy is present, these are high risk patients. And if these patients have, in addition, portal vein thrombosis, these patients like in HCC will bleed more often. We looked into whether HVPG, which is common for esophageal varices as a predictor, does it work for gastric varices? As you will see that 38% of the patients have shunt, and those who have shunt have much lower portal pressure. So they are in a way decompressed by themselves. And therefore, these patients who bleed or do not bleed with gastric varices, do not have a correlation with HVPG. And that is why TIPS sometimes does not work well in them. However, one thing is clear, all bleeders have pressures above 10, not 12, not 16. Now, several people tried to find out if the splenic blood flow can be a predictor. And as you can see, these are large IGV1s. And here, those patients who had a blood flow of more than 499 or almost 500 ml per minute, these are the patients. So these are short gastric varices, as you can see, and the flow can be a certain. So you can easily find out by an EUS what is the likelihood of bleeding. Now, these are predictors of re-bleed. So the gastric varice has bled in the past. And for esophageal varices, similarly, presence of a nipple sign or RCS will indicate. Or if you do a EUS, you will find out that presence of paraesophageal, perigastric varices, perigastric complexes are indicators. And this group from Taiwan, they identified presence of red whale signs, perigastric veins, and sinoacrylate, if required, more than 4 ml, and gave a score of three or more as predictor of re-bleeding from gastric varices. I'm showing you this just to say that you may block one area, but the patients can bleed from other areas. So this patient had both GOV1 and had IGV1 as a bleeding. And therefore, just blocking IGV1 would increase the size of junctional varics from where they can bleed. So let's go through some of the acute management, preventing re-bleed, and preventing first bleed. So what are the therapeutic strategies? So if you have esophageal varices which are extending to the lesser curve, you will actually do band ligation, endoscopic variceal ligation. If they are extending on to the fundal side, then you will block them. In addition, simultaneously, you will inject into the gastric varices. For patients who have isolated gastric varics, of course, glue is the choice. I guess it is still not available in the US, but most of the rest of the world uses it. And for other areas into the stomach atopic varices, also glue is the choice. Here is an active bleed, a nipple sign. Here's another patient with GOV1, actively bleeding. GOV2, actively bleeding. The ordinal varics, actively bleeding. And these are several studies which have been done using endoscopic therapy. And histoacryl has been used, and generally the success rate is close to about 100. So immediate homeostasis, hemostasis can be achieved in almost all the patients. I'll show you some small tricks, not that people are not experts here, but just to show you that there is an active gastric variceal bleeder. And the moment you will put a catheter in this, an injector into this, you will see that the blood will come into the injector, and that is known as a red catheter sign. I hope I can show you that fast. Yeah, so the moment you have the injector in it, so it's a high pressure varic, so please remember that this is like esophageal varices, and the blood will come, and you have to clear it up and keep it for a minimum of 15 to 30 seconds. And this video is not for doing any further teaching, but to say that the needle has to be very long. It should be four to six millimeter long needle. Don't use small injector needles for injection. And once you have these two or three tricks, almost all the patients, you will achieve success. So a patient who has come with an active acute bleeding, we resuscitate the way we resuscitate for others. Patients with active bleeding commonly glue either directly or using some people with expertise can use EUS and coil or can place clips. But for us and most of the Asians, glue is enough by direct injection. Bleed control is achieved in almost all. Those who do not get a bleed control as per the Bavino consensus, a second injection is generally avoided. And in these patients, either you can go for a salvage tips or BRTO. If there is a patent spinoportal axis, otherwise one can do in BRTO. Here I'm showing you a EUS guided injection of the glue. Here, these veins were not very clearly visible because of the blood clot. Of course, you can change the position, but in these patients, a EUS guided injection could be helped. Some of our colleagues have started using endoclips, which to me looks very scary. So you apply endoclip on a gastric varix and then inject, but I think you really need some expertise for that. And in those hands, it works well. However, if you have a failed glue injection, which is sometimes when there is a massive bleed or a blood clot or a portal vein, or which has been thrombosed in such patients, an emergency tips can be performed and this really can help. So here is a patient who had a Sank's taken tube, which is not very effective. And then you have to put a tips into such patients. This is to show you, now we will come to patients who have a secondary prophylaxis. Now, this trial, which was done about 12 years ago, included patients for preventing re-bleed. First bleed has occurred. And this was to compare beta blockers versus sinoacrylate. And as you would notice that, the bleeding free rates were much higher once the glue is injected. The reason is these patients have got a very high flow rate. And a two year re-bleeding free interval was much higher for sinoacrylate glue. Also, the cumulative survival was 90% after glue compared to the beta blockers. However, there are several groups and there are several patients who require other therapies. And these are interventional radiology techniques. One, I showed you tips. Tips, these are studies which were done. All these patients had a pressure which was about 12, about 270 patients. In them, hemostasis could be achieved in more than 90% or so. However, re-bleed also occurs and also mortality is present. These are sick patients. So therefore, if you can have expertise in glue injection, it is as good as doing tips. Otherwise, tips is a good option. This Japanese technique of putting through the IVC and into the splenic and the renal vein communication, a balloon to occlude. And after putting balloon, you can give either coils or you can use ethanolamine or any other agent. This is balloon retrograde transvenous obliteration. So here is a patient of IGV1. This is taken from a Korean study. Very large gastro-renal shunt. And after having injected, this patient had total disappearance of the large varic. This is one of our patients, pre-BRTO. Very large linorenal gastric varices. And after the injection, this patient has total disappearance of the varices. This slide I'm showing you especially to make you aware when BRTO can fail. So normally, here is an efferent and this is the efferent. You can easily block this area, gastric varices. Here is somebody who has double efferents. One efferent is this side. One is the other side. And third is the posterior gastric. You may fail in these patients. A third patient is a category which has a aberrant bridge between the two. And this gastric varix and the horizontal shunt will make BRTO failure. So please do not think that every patient with BRTO will succeed. There are several variations, therefore, of BRTO. One is simple, blocking the shunt. Then you can use a clot which is called as plug-assisted, sorry, plug-assisted retrograde obliteration or coil-assisted. So nowadays, most of our radiology colleagues will do parto or carto to handle different feeding vessels in them. Here is another study taken from literature from Korea. It shows you that applying large, because here there were multiple shunts, side shunts, applying coil as well as applying the glue was helpful in bleeding gastric varices. This is a comparison to show you that patients can have success of about 84% to 97%. And these patients can still re-bleed. So you can have TIPS, you can have carto, parto or BRTO. All these options are available in a good center. And therefore, management of gastric varices has significantly improved. I have discussed with you secondary prophylaxis. I have discussed with you salvage procedures where the bleeding sometimes occurs and you cannot control. Let me take you to primary prophylaxis of gastric varices. So one more time, I would like to remind you which patient will bleed. And these are largely GOV2, the fundal site, and the IGV1 varices. A high-risk varix is one which is more than two centimeters or the MELD is above or equal to 17. And in such patients, there is a high likelihood of bleeding. And the splenic blood flow can be sometimes very high. And survival is, in these patients, low. Now, this study was also done about 12 years ago where we took three groups of patients. One group had no treatment. So these were high-risk, more than 20-millimeter varices. And you can see in two years' time, almost half of them would bleed. And these were compared with cyanoacrylate, that is prophylactic glue, or beta blockers. There was no major difference between these two. However, there was a difference between group one and group three specifically. This also showed you the survival advantage of patients who receive glue therapy. So it removed the fear that you can inject primarily large gastric varices. And of course, you have some advantage, survival advantage. Now, these are patients of gastric varices who have never bled. Tips is never done in them. But today, you can do BRTO. Prophylactically, and BRTO will help you preventing into going into encephalopathy. And it might also reduce your shunt. So I've shown you acute bleed. I've shown you the prevention of bleed. And also, primary prophylaxis of these patients. This is again the same patient which showed you. I hope I'm not gone in the, oh, I'm going in the reverse direction. Whatever. I call it. Now, I want to show you these two slides. Despite our expertise over years, I'm not able to classify these patients. Because here, the whole fundus is full of varices. Again, one more patient I'll show you. This is also a patient who has the whole of fundus full of varices. So when you search a patient, what is your diagnosis? The diagnosis would be this is a portal vein which is totally gone. And exactly this patient had left-sided portal hypertension, had a splenic vein thrombus. All the veins were going into the stomach. And no amount of injection of gastric varices would work. Some of these patients would need a devascularization or sinister portal hypertension management. So let me summarize, ladies and gentlemen. The field of gastric varices is still evolving. One in five of your patients with bleed will have gastric varices. And those who have gastric varices, one in three will bleed. The bleeding is highest with IgV1, which is isolated gastric varices in the fundus, much more than in the GOV2, and the least 6% in ectopic varices. A high-risk varice is more than 20 millimeter with RCS in a patient who is probably child's B, late, or C, and those who have gastropathy. Bleed will occur in about one in two of these patients with high mortality. If the pressure is less than 10, generally the bleed is not from gastric varice. However, if the pressures are high, you can do tips if the portal vein is fated. For active, for secondary prophylaxis, or primary prophylaxis, sinoacrylate glue injection is still the best. You can combine it either directly or with EUS techniques. BRTO, PARTO, CARTO are emerging techniques. I do hope with this, you can manage your patients with gastric varices much better. Thank you.

bleeding gastric varices

predicting bleeding risks

diagnostic techniques

treatment options

portal hypertension

endoscopic variceal ligation