Diagnostic dilemma in gastric varices: Endoscopic ultrasound resolves the issue (with videos).

Gastroesophageal varices are one of the most serious complications of portal hypertension. One-third of patients with varices develop variceal hemorrhage.[1] Bleeding from gastric varices is more severe and is associated with higher morbidity, transfusion requirements and mortality than esophageal varices.[2] Despite significant improvements in various treatment modalities, mortality due to bleeding from gastric varices remains very high.[2] Gastric varices are usually classified as per Sarin's endoscopic classification, which is based on the endoscopic appearance and location of the varices.[3] Sometimes gastric varices are mistaken for large gastric folds or submucosal tumors and endoscopic ultrasound (EUS) helps in differentiating them.[4] EUS is useful in identifying the collateral pathways and inflowing and out flowing perforators.[5] EUS has also been used in evaluation and injection of glue into perforators and paragastric varices.[6] We are presenting a case of isolated gastric varices (IGV2), in which there was diagnostic dilemma with a differential diagnosis of submucosal tumor. The dilemma was resolved by EUS.

The 65-year-old lady presented in an emergency with complain of massive upper gastrointestinal (GI) bleed and shock requiring several units of packed cells for resuscitation. Investigations before the transfusions revealed hemoglobin (Hb) 4.6 g%, total lymphocyte count 8200, differential leukocyte count polymorphs 68%, lymphocytes 32%, blood urea 30 mg/dL, Serum creatinine 1.1 mg/dL, serum bilirubin 9 mg/dL, aspartate aminotransferase 38 U/L (normal: 14-40 U/L), alanine aminotransferase 28 U/L (normal: 10-40 U/L), and an alkaline phosphatase value of 135 U/L (normal: 38-126 U/L). The markers for hepatitis B and C were negative. Ultrasound abdomen in emergency revealed a portal vein diameter of 11 mm and a normal liver with mild splenomegaly. After 8 h of resuscitation, repeat Hb was 9.6 g%, and the patient was hemodynamically stable. An upper GI endoscopy revealed normal esophagus and fundus of the stomach. Examination of the body of the stomach on retroflexion showed the following pictures [Figures 1a–c]. An EUS was done [Figures 2a–c].[2]. The diagnosis of isolated submucosal gastric varices was suspected from endoscopic appearance, and the confirmation was done by EUS. An EUS was also able to show the inflowing and outflowing perforators to the gastric varices [Figure 3 Videos 1 and 2]. Two milliliter of n-butylcyanoacrylate glue was injected into the varices and a repeat EUS after glue injection showed absence of blood signals in submucosa of the stomach wall [Figure 4]. Follow-up ultrasound showed coarse echo-texture of liver and a diagnosis of cirrhosis of the liver was made.

Figure 1

(a) Examination of the body of the stomach on retroflexion showed a large submucosal bulge in the body of stomach (b) There were multiple smaller bulges near the large bulging area (c) The largest bulge had central ulceration

Figure 2

(a) An endoscopic ultrasound showed anechoeic areas in submucosa, which showed color flow on application of color Doppler (b) An endoscopic ultrasound showed anechoeic areas in submucosa which showed color flow on application of color Doppler (c) The outflowing perforator was identified by the blue coloured flow of the varix through the muscularis propria

Figure 3

The perforator could be traced to the para gastric varices

Figure 4

Endoscopic ultrasound after glue injection showed absence of blood signals in submucosa of stomach wall

Variceal bleed is a major cause of morbidity and mortality in case of portal hypertension. Gastric variceal bleeding is more severe and associated with a worse outcome compared with esophageal varices.[2] The ulceration on gastric varices without any intervention is uncommon, and it produces diagnostic dilemma especially in the setting of IGV type II. In this case there was ulceration of varix without any prior treatment. Hence, there was suspected differential diagnosis of ulcerated submucosal tumor as patient had normal liver on ultrasonography and no esophago-fundal varices. This diagnostic dilemma was resolved by EUS. The computed tomography angiogram or magnetic resonance angiogram can also show the IGV2, but the layer-wise relationship of the varices to the stomach wall is difficult to establish.

Once the diagnosis is confirmed glue injection is the preferred therapy for gastric varices.[7] In this case glue injection was given in the IGV2 after confirmation of the diagnosis and patient responded well to treatment. The confirmation of satisfactory glue injection was made by a follow-up EUS. The other possible option of obliteration of gastric varices is by coil injection.[8]

Endoscopic ultrasound is an excellent diagnostic modality for diagnostic evaluation of gastric varices and is useful in resolving the dilemma if the diagnosis of gastric varices is in doubt.

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