Disease definition and epidemiology
Diagnosis
Endoscopic evaluation-based diagnosis and classification
The relevance of collateral pathway anatomy in gastric varices
Cross-sectional imaging-based evaluation of the gastric variceal complex
Hemodynamic classification of gastric varices
Based on afferent/inflow hemodynamics
Classification system | Clinical relevance |
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Kiyosue classification | In Type A, shunt occlusion as the treatment of modality would suffice to control variceal bleeding not controlled with endoscopic therapy. In type B, feasibility of shunt occlusion might be less and hence transjugular intrahepatic portosystemic shunt placement is a better option to obliterate all of the collateral pathways In type C, transjugular intrahepatic portosystemic shunt placement along with shunt emobilization of large portosystemic shunts could be the best option in ideal candidates In Type D, in the presence of endoscopic failure, transjugular intrahepatic portosystemic shunt placement could become the best option |
Type A: single draining shunt Type B: single shunt and multiple collateral veins B1: small collateral veins B2: medium sized collateral B3: large collateral veins with high flow without shunt Type C: more than one shunt present C1: small sized second shunt that cannot be catheterized C2: presence of second shunt large enough to be catheterized Type D: shunt is not present and the varices drain through small collaterals | |
Saad–Caldwell classification | In Type D, embolization procedures may not suffice to prevent rebleeding or control active bleeding due to the complex anatomy, and hence, transjugular intrahepatic portosystemic shunt placement could become the best option for prevention of further bleeding |
Type A: single draining shunt Type B: single shunt and multiple collateral veins B1: small collateral veins B2: medium sized collateral B3: large collateral veins with high flow without shunt Type C: more than one shunt present C1: small sized second shunt that cannot be catheterized C2: presence of second shunt large enough to be catheterized Type D: shunt is not present and the varices drain through small collaterals D1: predominance of systemic vein drainage is not obvious and any vein, out of inferior phrenic, hemiazygos tributaries, and intercostals veins or adrenal veins may be predominant D2: morphology similar to D1, but predominant systemic venous draining vein is usually 4.3 mm in diameter through unconventional systemic veins | |
Hirota—BORV classification | In Type A, shunt embolization can help obliterate gastric varices In Type B, transjugular intrahepatic portosystemic shunt placement with or without shunt embolization can help obliterate varices In Type C, transjugular intrahepatic portosystemic shunt placement and shunt embolization need to be performed for large shunts for complete variceal disease management In Type E, an antegrade approach for shunt embolization is more feasible than a retrograde approach since balloon sizes may not be available and the shunt flow is high |
Type A: single draining shunt Type B: single shunt and multiple collateral veins B1: small collateral veins B2: medium sized collateral B3: large collateral veins with high flow without shunt Type C: more than one shunt present C1: small sized second shunt that cannot be catheterized C2: presence of second shunt large enough to be catheterized Type D: shunt is not present and the varices drain through small collaterals Type E: gastrorenal shunt too large for balloon occlusion procedures |
Based on efferent/outflow hemodynamics
Classification system | Clinical relevance |
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Hirota classification | Only endoscopic guided or endoscopic ultrasound guided therapy may help in obliteration of varices of Type 1 and 2 Transjugular intrahepatic portosystemic shunt placement is ideal for Type 3 and 4 related bleeding Transjugular intrahepatic portosystemic shunt placement and shunt embolization is ideal in Type 5 |
Grade 1: gastric varices well opacified without any collateral vein evidence Grade 2: contrast opacification in gastric varices for ≥ 3 min in the presence of small and few collateral veins Grade 3: contrast opacification of gastric varices partial and disappears within 3 min with medium to large collateral veins which were few in number Grade 4: non-contrast opacification of gastric varices and presence of many large collaterals Grade 5: shunt cannot be occluded because of very large size of shunt and rapid blood flow | |
Fukuda classification | Based on hemodynamic features involving the superior mesenteric and celiac angiography findings In Type 2 and Type 3 with left gastric vein dominance, rebleeding can be noted with only endoscopic management and hence transjugular intrahepatic portosystemic shunt placement may become the treatment of choice In those associated with shunts, shunt embolization with or without transjugular intrahepatic portosystemic shunt placement may be superior to only endoscopic therapy |
Type 1: left gastric vein dominant gastric variceal complex Type 2: separation between the esophageal varices (left gastric vein dominant) and the gastric varices (posterior gastric vein/superior gastric vein dominant) Type 3: highly complex system consisting of both right and left sided feeding vessels Type 4: right sided dominance only of gastric variceal system | |
Matsumoto classification | Classification system for gastric varices for predicting the aggravation of esophageal varices after balloon occluded retrograde transvenous occlusion procedure Based on left gastric angiography Aggravation of esophageal varices grade occurs in Type 1B varices |
Type 1: portosystemic flow in the gastrorenal shunt A: hepatopetal flow B: hepatofugal flow Type 2: no portosystemic flow in the gastrorenal shunt A: hepatopetal flow B: hepatofugal flow |