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We read with interest the article by Tripathi et al (Gut 2002;51:270–4) on the therapeutic effect of transjugular intrahepatic portosystemic stent shunt (TIPSS) on gastric variceal bleeding. They concluded that TIPSS could only improve mortality in patients with bleeding at a portal pressure gradient (PPG) >12 mm Hg. When treating gastric varices, we should pay attention to the fact that the behaviour of these varices varies according to their location. Isolated fundal varices (FV) are confined to the fundus only (or the cardia and fundus), and are not associated with oesophageal varices. Chikamori and colleagues1 reported that the portoazygos venous system contributes to the formation of oesophageal and cardiac varices whereas the portophrenic venous system contributes to the formation of FV. They also showed that the main (85%) drainage route in patients with FV was via a gastrorenal shunt.
According to Watanabe et al, in a series of patients who developed FV, superior mesenteric venous flow was diverted away from the liver and directed into the veins feeding the varices. Therefore, the portal venous pressure of patients with large FV is quite low but collateral flow into the FV is abundant. Additionally, such patients are likely to develop hepatic encephalopathy.2 We believe that some of the FV patients in group 1 treated by Tripathi et al had this pattern of portal haemodynamics. Gastric variceal bleeding is massive, and is frequently more severe than bleeding from oesophageal varices. As the course of patients with FV is adversely modified by variceal bleeding, identification of large high risk FV and their prophylactic obliteration has been proposed.3 However, high risk FV have not been fully defined. Kim et al determined the one year probability of bleeding in relation to all possible combinations of two endoscopic variables (variceal size and the presence of red spots) for patients in Child’s class A, B, and C.4 According to their criteria, FV with a one year probability of bleeding ⩾16% can be considered as high risk and are comparable with high risk oesophageal varices.5 How should we treat FV in patients with a low PPG?
Balloon occluded retrograde transvenous obliteration (B-RTO) is a new interventional radiology technique that was recently developed in Japan.6 B-RTO is similar to but less invasive than TIPSS and it achieves excellent prevention of recurrent bleeding with few major complications (fever, haemoglobinuria, and worsening of oesophageal varices), even in patients with poor liver function.7 Additionally, this procedure can improve hepatic encephalopathy.8 The main limitation of B-RTO in an emergency setting seems to be the requirement for temporary control of bleeding. We recommend elective B-RTO for the management of bleeding FV associated with a gastrorenal shunt at any PPG value. A prospective randomised trial of TIPSS versus B-RTO should be performed to determine the management of bleeding FV with a PPG ⩽12 mm Hg.
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