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Role of multi-detector row CT angiography in the management of gastric fundal varices
We read with great interest the article by
regarding the superiority of multi-detector row CT (MDCT) angiography over endoscopic ultrasound for the detection and characterisation of submucosal gastric fundal varices (FV).
We strongly agree that MDCT angiography provides excellent visualisation of FV, as well as afferent and efferent veins, and that it provides valuable anatomical information for deciding the therapeutic strategies for FV (fig 1A, B).1,2
Iwase and colleagues3 divided FV into localised and diffuse types using MDCT angiography. This classification resembles the findings obtained by investigation of resected or autopsied stomachs.4 According to Iwase and colleagues,3 diffuse FV are more difficult to obliterate with cyanoacrylate than localised FV. Diffuse FV may be better treated with balloon occluded retrograde transvenous obliteration (B-RTO).5
Although FV with a high risk of bleeding have not yet been fully clarified, they are defined according to the criteria proposed by Kim and colleagues2 in Japan. Because high risk FV are easily detected endoscopically, it is not necessary to distinguish FV from perigastric collateral veins by MDCT angiography.
MDCT angiography can also provide useful information for evaluation of the effect of treatment of FV.5,6 Obliteration of the afferent veins as well as the actual varices is important to prevent recurrence.5 If these vessels are not visualised by MDCT angiography after therapy, FV will rarely recur.5,6 With regard to the treatment of FV reported by the authors, we also have some comments. Firstly, they treated a patient by transjugular intrahepatic portosystemic shunting (see fig 2 in Willmann et al). However, as the patient had a type 2 portal haemodynamic pattern, as classified by Kanagawa and colleagues,7 B-RTO would have been preferable if his portal pressure gradient was less than 12 mm Hg.2
Secondly, we would like to ask the authors how they treated the patient presented in fig 3? As the varices seem to be so-called GOV2, as classified by Sarin and Kumar,8 they could be treated by endoscopic sclerotherapy with the oesophageal varices.
We thank Dr Matsumoto et al for their interest in our work.
Balloon occluded retrograde transvenous obliteration (B-RTO) is a recently described interventional radiology technique which allows effective treatment of gastric varices, similar to but less invasive than transjugular intrahepatic portosystemic shunt stent (TIPSS).1 It has recently been shown that B-RTO of gastric varices can even be performed through the left inferior phrenic vein which represents the efferent vein of gastric varices.2 There is no doubt that B-RTO through the left inferior phrenic vein would have been an option for the treatment of the patient shown in fig 2 of our article (
However, since the portal venous pressure gradient in this particular patient was 28 mm Hg, we preferred to place a 10 mm diameter TIPSS in this particular patient.
The patient illustrated by fig 3 in our study (
) was classified as having gastro-oesophageal varices type 2 (GOV-2), according to the endoscopic classification proposed by Sarin and Kumar.3 This patient underwent endoscopic sclerotherapy.