Available online 30 September 2025, 101082

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Gastric varices can pose both diagnostic challenges and serious risk of life-threatening hemorrhage in patients with cirrhotic and non cirrhotic portal hypertension. Management requires a multidisciplinary approach, with gastroenterology playing a key role in diagnosis, endoscopic assessment, and initial treatment strategies. Interventional radiology plays a pivotal role in treatment with advanced portal decompression techniques, Together, gastroenterology and Interventional radiology specialties provide an individualized patient tailored approach to optimize diagnostic and treatment strategies in patients with gastric varices. This article offers a descriptive approach to diagnosing and managing GV.

Section snippetsGastric Varices

Dilated mucosal/submucosal veins in the stomach in the setting of portal hypertension have reported incidences ranging from 17% to 25% (1, 2, 3, 4).

GV may be isolated or can occur with esophageal varices. Isolated gastric varices develop in both cirrhotic and noncirrhotic portal hypertension. In both scenarios, high portal vein and splenic vein pressures are causative and can result from splenic vein /portal vein thrombosis in the non-cirrhotic scenarios. Bleeding from GV is reported as more

Classification of Gastric Varices

Endoscopic classification of gastric varices describes the anatomic location detected on endoscopy, and the most commonly used terminology by gastroenterologists is the Sarin classification (Figure 1). In this classification scheme for isolated GV, type 1 (IGV1) is seen in the gastric fundus, and type 2 (IGV2) is more distal within the stomach (1).

The Sarin classification for non-isolated GV depicts gastroesophageal varices type 1 (GOV-1) as the most common type, arising from the lesser gastric

Antegrade Transvenous Obliteration (ATO)

Percutaneous transportal obliteration of the varices can be achieved from either a transhepatic or transjugular approach to the portal vein. Percutaneous transhepatic obliteration (PTO) was first described by Lunderquist in 1974 using a combination of sclerosing and thrombosing agents including glucose and thrombin. High re-bleeding rates were reported with this technique, limiting its universal utility (11,12).

With improved obliterating agents, notably cyanoacrylate and Sotradecol foam, the

Retrograde Transvenous Obliteration (RTO)

While antegrade approaches are favorable in treating isolated GV and GOV without an accessible efferent pathway, such as a prominent GRS, if the varix has an efferent limb that can be reached from systemic venous access, the retrograde approach is often a first-line approach. It has been reported that approximately 85% of isolated GV have a GRS. However, gastric varices without a GRS are not uncommon, accounting for 10% to 15% of cases (23). In these situations, efferent flow could be the

Outcomes

The clinical outcomes of PARTO, CARTO, and BRTO demonstrate their effectiveness in treating GV. Each procedure offers distinct advantages and limitations. PARTO boasts high technical success rates (90–100%) and lower recurrence rates compared to BRTO, primarily due to the stable occlusion achieved with vascular plugs. CARTO also achieves high technical success rates, typically exceeding 90%, and is effective in managing gastric variceal bleeding, serving as a valuable alternative when vascular

Conclusion

Gastric variceal bleeding is a potentially fatal condition where interventional radiologists play a crucial role in both diagnosis and management. Clinically, variceal bleeding – regardless of location – occurs when the porto-systemic gradient exceeds 12 mm Hg. According to Laplace’s Law, variceal wall tension is proportional to the varix diameter and transmural or portal pressure. Bleeding occurs when the tension exceeds the varix's elastic limit. GVs often have larger diameters and, by the

Uncited References

(32,33,34,35)

Disclosure

The author’s report no potential conflicts of interest. (Author’s please confirm, complete and correct)

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