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Case 142: Gastroscopic problem

This elderly gentleman had presented with significant haematemesis.

1. What does the bleeding seem to be coming from judging by the nature of its flow?

The constant, non pulsatile flow would indicate venous bleeding. Venous bleeding in the stomach would most likely originate from gastric varices. These are difficult to treat and can bleed significantly. Although similar in pathogenesis to oesophageal varices, their treatment differs.

2. What are your options for treatment?

Treating gastric varices can be very challenging. The Sengstaken-Blakemore tube may have some utility for bleeding varices near the gastroesophageal junction, but would have little utility for varices in the fundus or further down in the stomach.

Successful hemostasis and obliteration of gastric varices has been reported with intravariceal injections of sclerosant, absolute alcohol, thrombin, and cyanoacrylate. This methods could all be used acutely to stem rapid bleeding.

There is less experience with Endoscopic varicoele banding in this setting. The problem with banding would be ulceration when the band falls off, potentially causing significant bleeding. This outcome would be especially worrying if banding was used as primary prophylaxis when the patient was not actively bleeding.

Though criteria for varices that are at high risk for bleeding have been developed, there are no reports of attempts at prophylactic treatment using endoscopic based therapy. Medical management is similar to the treatment of esophageal varices. Vasopressin and octreotide are useful for control of acute bleeding, and beta-blockers and long acting nitrates may prevent subsequent bleeding.

PubMed - Gastric varices
Visible human journal of endoscopy - Gastric varices
Wikipedia -Gastric varices

Case Editor:

Mr Trevor Mcquillan - General Surgeon, The Northern Hospital, Melbourne, Victoria, Australia.