Gastric varices: a contemporary review of vascular anatomy and therapeutic strategies.

Gastric varices (GV) are found in 20% of patients with portal hypertension and bleed infrequently, but are associated with greater blood loss, higher transfusion requirements and mortality than oesophageal varices. The vascular anatomy of GV is characterised by different afferent and efferent pathways, which vary depending on its anatomical location. Contemporary radiological classification systems complement traditional endoscopic systems and assist in selection of the optimal treatment modality in an individual patient. Endoscopic cyanoacrylate injection remains the standard therapy for acute GV bleeding and achieves high rates of primary haemostasis, but is limited by incomplete obliteration, recurrent bleeding and risk of systemic embolisation. Endovascular interventions, including transjugular intrahepatic portosystemic shunt and retrograde transvenous obliteration (RTO), have demonstrated superior long-term bleeding control in recent randomised clinical trials, although each has distinct indications and adverse-event profiles (ascites, aggravation of oesophageal varices and hepatic encephalopathy). Endoscopic ultrasound (EUS)-guided interventions enable real-time visualisation of vascular anatomy and targeted treatment with coils, glue or thrombin, resulting in improved obliteration rates and lower recurrence. However, there are limited direct comparisons between these modalities in present literature. The availability of multiple treatment modalities has resulted in the evolution of the management of GV from conventional endoscopic therapy towards individualised, anatomy-driven treatment strategies incorporating EUS-guided and endovascular interventions. This review summarises the contemporary understanding of GV anatomy, pathophysiology and therapeutic strategies.