Giri S, Patel RK, Tripathy TP, Praharaj DL, Chavan R. Pathophysiological management of gastric varices: From hemodynamics to targeted therapies. World J Gastrointest Pathophysiol 2026; 17(3): 122115 [DOI: 10.4291/wjgp.122115]
Corresponding Author of This Article
Suprabhat Giri, Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Kushabhadra Campus, 5, KIIT Road, Patia, Bhubaneswar 751024, Odisha, India. supg19167@gmail.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
review-article
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Suprabhat Giri, Dibya Lochan Praharaj, Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar 751024, Odisha, India
Ranjan K Patel, Tara Prasad Tripathy, Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneshwar 751019, Odisha, India
Radhika Chavan, Department of Gastroenterology, Bharati Vidyapeeth, Pune 411030, Mahārāshtra, India
Co-first authors: Suprabhat Giri and Ranjan K Patel.
Author contributions: Giri S contributed to the conception and design of the manuscript; Giri S, Patel RK, and Chavan R drafted the initial manuscript. All authors contributed to the critical revision of the initial manuscript. All authors contributed to the literature review, analysis, data collection, and interpretation. All authors approved the final version of the manuscript. Giri S and Patel RK contributed equally to this work as co-first authors.
AI contribution statement: AI tools were used for language polishing.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Corresponding author: Suprabhat Giri, Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Kushabhadra Campus, 5, KIIT Road, Patia, Bhubaneswar 751024, Odisha, India. supg19167@gmail.com
Received: April 10, 2026 Revised: May 25, 2026 Accepted: June 12, 2026 Published online: September 22, 2026 Processing time: 151 Days and 10.9 Hours
Abstract
Gastric varices (GV) are a distinct and clinically challenging manifestation of portal hypertension characterized by complex vascular anatomy and unique hemodynamic behavior. Unlike esophageal varices (EV), GVs arise from interactions between afferent portal inflow, large variceal reservoirs, and spontaneous portosystemic shunts, resulting in a low-pressure, high-flow system that often responds poorly to conventional pressure-reducing therapies. Consequently, management strategies extrapolated from EV are frequently inadequate. Advances in endoscopic ultrasound (EUS), cross-sectional imaging, and interventional radiology have facilitated a paradigm shift toward a pathophysiology-driven approach. Contemporary evaluation integrates endoscopic classification based on anatomical location (Sarin), EUS for assessment of feeding vessels and flow dynamics, and computed tomography/magnetic resonance imaging for mapping afferent and efferent pathways using Kiyosue and Saad-Caldwell classifications. These frameworks enable hemodynamic triage into shunt-dominant, pressure-dominant, and complex patterns, which directly inform therapeutic selection. Endoscopic therapies, including cyanoacrylate injection and EUS-guided coil ± glue embolization, target the variceal reservoir and inflow, providing effective local control. Radiologic interventions address systemic hemodynamics, with retrograde transvenous obliteration (Balloon-occluded retrograde transvenous obliteration/plug-assisted retrograde transvenous obliteration/coil-assisted retrograde transvenous obliteration) preferred for shunt-dominant varices and transjugular intrahepatic portosystemic shunt for pressure-driven disease. Surgical options remain relevant in selected conditions such as left-sided portal hypertension. Clinical modifiers, including hepatic reserve, encephalopathy, ascites, and portal vein patency, further refine treatment decisions. A multidisciplinary, mechanism-based strategy is essential to optimize outcomes. Future research should focus on integrated classification systems and prospective comparative studies to establish standardized, individualized management algorithms.
Core Tip: Gastric varices require a pathophysiology-driven management strategy distinct from esophageal varices. Therapy selection should be guided by hemodynamic classification, integrating Sarin (location), Kiyosue and Saad-Caldwell (inflow-outflow anatomy), and clinical factors. Shunt-dominant varices are best treated with Balloon-occluded retrograde transvenous obliteration or its variants, while pressure-dominant disease requires a transjugular intrahepatic portosystemic shunt for global decompression. Endoscopic ultrasound-guided coil ± glue therapy offers precise, flow-directed treatment in complex anatomy or high-risk patients. Clinical modifiers such as hepatic encephalopathy, ascites, liver reserve, and portal vein patency are critical in decision-making. A multidisciplinary approach combining endoscopic, radiologic, and surgical modalities is essential for optimal and durable outcomes.
