variceal bleeding is the most common lethal complication of cirrhosis , with a mortality rate of 20% .
gastroesophageal varices ( govs ) are present in 50% of cirrhotics , and approximately 25% of patients with portal hypertension have gastric varices .
gastric varices are commonly classified as govs ( gastric varices in continuity with esophageal varices ) and isolated gastric varices ( igvs ) .
these are further divided into gov1 ( govs along the lesser curve of the stomach ) , gov2 ( govs along the fundus ) , igv1 ( igvs in the fundus ) , and igv2 ( igvs in the gastric body , pylorus , or antrum ) .
although the prevalence and risk of bleeding of gastric varices are lower than those of esophageal varices , gastric variceal bleeding tends to be more severe , requires more transfusions , and is associated with higher mortality ( ~45% ) .
gastric varices tend to be larger and more tortuous compared with esophageal varices , characteristics that , combined with their anatomical location ( particularly fundic varices ) , make endoscopic management more challenging .
current management strategies for gastric varices include pharmacotherapy ( -blockers and vasoactive agents ) , endoscopic therapy ( band ligation , thrombin , and tissue adhesives ) , transjugular intrahepatic portosystemic shunt ( tips ) placement , and surgical intervention .
therefore , recommendations for management of gastric varices are based on recent prospective and retrospective studies , expert consensus opinion , and experience with esophageal varices .
the pathophysiology of gastric varices is not as well understood as that of esophageal varices ; however , the former are mostly seen in patients with cirrhotic portal hypertension .
no studies to evaluate pharmacologic therapy or endoscopic therapy for primary prophylaxis of gastric varices have been performed , and recommendations are based primarily on the guidelines for managing esophageal varices .
large gastric varices with red color signs , especially in patients with advanced liver disease ( child 's class c ) , are most likely to bleed .
endoscopic therapy and tips are both considered first - line treatments for gastric variceal bleeding ; however , current guidelines favor endoscopy as the preferred initial intervention .
endoscopic therapeutic options for gastric variceal bleeding include band ligation , tissue adhesives , thrombin , and sclerotherapy .
the greatest evidence exists for tissue adhesives such as cyanoacrylate ( n - butyl-2-cyanoacrylate , 
cyanoacrylate undergoes rapid polymerization on contact with living tissues and obliteration of varices occurs when the injected cyanoacrylate adhesive hardens on contact with blood .
two randomized controlled trials have compared cyanoacrylate injection with variceal band ligation , showing mixed results for initial hemostasis but reduced rebleeding rates with cyanoacrylate ( 22% versus 44% and 31% versus 54% ) .
another study compared cyanoacrylate injection with sclerotherapy and found better control of initial hemostasis as well as lower rebleeding rates with cyanoacrylate .
meticulous adherence to technique is crucial when using tissue adhesives to prevent irreversible damage to endoscopes caused by polymerization .
a recent study reported the use of endoscopic ultrasound to guide injection of feeding veins with excellent results ; however , the risk of damaging expensive equipment may prevent its widespread usage .
complications of tissue adhesives include embolization , with case reports of portal vein embolization , coronary emboli , splenic infarction , pulmonary emboli , and cerebral stroke [ 13 - 16 ] .
thrombin is a promising agent that does not carry the risk of embolization and damage to equipment .
a recent study using bovine thrombin to control gastric variceal bleeding demonstrated a hemostasis rate of 92% and no episodes of rebleeding .
several other studies with thrombin have shown promising results [ 17 - 19 ] . however , controlled trials comparing thrombin with other agents are required before it is universally accepted .
the role of tips in the management of gastric varices alone or in comparison with esophageal varices has been investigated in multiple studies .
chau et al .   reported a 96% initial hemostasis rate and 29% rebleeding rate with tips in patients with fundal varices , and these were similar to the rates for cirrhotics with esophageal varices . in another retrospective series
comparing tips in 40 cirrhotics with gastric variceal bleeding and 232 patients with esophageal variceal bleeding , the rates of rebleeding were similar ( 20% versus 15% ) .
clearly , with hemostasis rates over 90% , tissue adhesives and tips are both highly effective management options for gastric variceal bleeding .
lo et al .   carried out a randomized controlled trial comparing tips ( n = 35 ) and cyanoacrylate glue ( n = 37 ) for secondary prophylaxis of gastric variceal bleeding .
however , the rebleeding rate was significantly higher in the cyanoacrylate arm compared with the tips arm ( 38% versus 11% ) . in a uk - based retrospective study ,
the two therapies were equally effective for initial hemostasis but patients with tips had a lower rebleeding rate ( 20% versus 35% ) .
however , tips was considerably more expensive than cyanoacrylate therapy . finally , in a recent retrospective study comparing tips ( n = 44 ) and cyanoacrylate therapy ( n = 61 ) for gastric variceal bleeding , rebleeding rates and mortality rates were similar between the two groups .
however , the tips group had increased morbidity requiring hospitalization and had a higher incidence of encephalopathy ( 11 versus 1 ) .
the pathophysiology of gastric varices is not as well understood as that of esophageal varices ; however , the former are mostly seen in patients with cirrhotic portal hypertension .
no studies to evaluate pharmacologic therapy or endoscopic therapy for primary prophylaxis of gastric varices have been performed , and recommendations are based primarily on the guidelines for managing esophageal varices .
large gastric varices with red color signs , especially in patients with advanced liver disease ( child 's class c ) , are most likely to bleed .
endoscopic therapy and tips are both considered first - line treatments for gastric variceal bleeding ; however , current guidelines favor endoscopy as the preferred initial intervention .
endoscopic therapeutic options for gastric variceal bleeding include band ligation , tissue adhesives , thrombin , and sclerotherapy .
the greatest evidence exists for tissue adhesives such as cyanoacrylate ( n - butyl-2-cyanoacrylate , 
cyanoacrylate undergoes rapid polymerization on contact with living tissues and obliteration of varices occurs when the injected cyanoacrylate adhesive hardens on contact with blood .
two randomized controlled trials have compared cyanoacrylate injection with variceal band ligation , showing mixed results for initial hemostasis but reduced rebleeding rates with cyanoacrylate ( 22% versus 44% and 31% versus 54% ) .
another study compared cyanoacrylate injection with sclerotherapy and found better control of initial hemostasis as well as lower rebleeding rates with cyanoacrylate .
meticulous adherence to technique is crucial when using tissue adhesives to prevent irreversible damage to endoscopes caused by polymerization .
a recent study reported the use of endoscopic ultrasound to guide injection of feeding veins with excellent results ; however , the risk of damaging expensive equipment may prevent its widespread usage .
complications of tissue adhesives include embolization , with case reports of portal vein embolization , coronary emboli , splenic infarction , pulmonary emboli , and cerebral stroke [ 13 - 16 ] .
thrombin is a promising agent that does not carry the risk of embolization and damage to equipment .
a recent study using bovine thrombin to control gastric variceal bleeding demonstrated a hemostasis rate of 92% and no episodes of rebleeding .
several other studies with thrombin have shown promising results [ 17 - 19 ] . however , controlled trials comparing thrombin with other agents are required before it is universally accepted .
the role of tips in the management of gastric varices alone or in comparison with esophageal varices has been investigated in multiple studies .
chau et al .   reported a 96% initial hemostasis rate and 29% rebleeding rate with tips in patients with fundal varices , and these were similar to the rates for cirrhotics with esophageal varices . in another retrospective series
comparing tips in 40 cirrhotics with gastric variceal bleeding and 232 patients with esophageal variceal bleeding , the rates of rebleeding were similar ( 20% versus 15% ) .
clearly , with hemostasis rates over 90% , tissue adhesives and tips are both highly effective management options for gastric variceal bleeding .
.   carried out a randomized controlled trial comparing tips ( n = 35 ) and cyanoacrylate glue ( n = 37 ) for secondary prophylaxis of gastric variceal bleeding .
however , the rebleeding rate was significantly higher in the cyanoacrylate arm compared with the tips arm ( 38% versus 11% ) . in a uk - based retrospective study ,
the two therapies were equally effective for initial hemostasis but patients with tips had a lower rebleeding rate ( 20% versus 35% ) .
however , tips was considerably more expensive than cyanoacrylate therapy . finally , in a recent retrospective study comparing tips ( n = 44 ) and cyanoacrylate therapy ( n = 61 ) for gastric variceal bleeding , rebleeding rates and mortality rates were similar between the two groups .
however , the tips group had increased morbidity requiring hospitalization and had a higher incidence of encephalopathy ( 11 versus 1 ) .
the initial steps in the management of gastric variceal bleeding are similar to esophageal varices and include attention to airway and obtaining intravenous access with prompt hemodynamic resuscitation , institution of vasoactive medications ( somatostatin analogues , octreotide , vasopressin , and terlipressin ) to reduce portal pressure by splanchnic vasoconstriction and prophylactic antibiotics followed by diagnostic and potentially therapeutic upper endoscopy ( figure 1 ) .
the next step in the management may be endoscopic injection of tissue adhesives or tips placement . with a lower complication rate , comparable hemostasis and survival rates , and lower cost ,
endoscopic therapy with tissue adhesives is likely to be the treatment of choice for acute bleeding and secondary prophylaxis in most patients . on the other hand
, tips will remain an important second - line modality in patients who fail endoscopic therapy .
however , additional controlled studies are needed before valid conclusions can be made , and individual patient characteristics must be considered in management decisions .
primary prophylaxis may be instituted with -blockers in patients with large varices with red color signs and advanced liver disease . further research on management of acute bleeding , primary prophylaxis , and comparisons between tissue adhesives and thrombin would be welcome .
 gastric variceal bleeding is a common problem in patients with cirrhosis and is associated with increased morbidity and mortality . 
 management is complex and includes pharmacotherapy , endoscopic therapy , and shunt placement . 
 recent studies indicate that endoscopic therapy with tissue adhesives has similar hemostasis rates and outcomes in terms of mortality as shunt placement but has a lower complication rate and therefore could be considered the first line therapy for acute bleeding and secondary prophylaxis of gastric varices . 
Introduction and context
Recent advances
Primary prophylaxis
Treatment of acute bleeding and secondary prophylaxis
Implications for clinical practice
Competing interests