Gastric varices are abnormal dilatation of venous structures in and around the gastric wall in the setting of portal hypertension. They are seen in approximately 20% of all portal hypertension patients. According to the Sarin classification, they are classified as gastroesophageal varices (GOV type 1 and 2) and isolated gastric varices (IGV type 1 and 2). On CT, they appear as enhancing serpentine tubular structures in or around the gastric wall. Their bleeding is more severe and mortality is higher compared to esophageal varices.
Age Range
35-75
Peak Age
55
Gender
Male predominant
Prevalence
Uncommon
Gastric varices develop through porto-systemic collateral vessel formation due to increased pressure in the portal venous system from portal hypertension. Normal portal pressure is 5-10 mmHg, which increases to >12 mmHg in portal hypertension leading to varix development. Cirrhosis is the most common cause (90%); splenic vein thrombosis leads to isolated fundal varices (sinistral portal hypertension). Portal venous blood is redirected to the submucosal and perigastric venous plexus of the gastric wall via the left gastric vein (coronary vein), short gastric veins, and posterior gastric vein; dilation of these vessels is visualized as varices. Their appearance as enhancing serpentine structures on CT reflects contrast flow in the lumen of these dilated venous structures; early arterial phase enhancement indicates the rapid flow characteristic of porto-systemic shunting. Spontaneous splenorenal shunt (SSRS) frequently coexists with gastric varices and affects treatment planning.
The pathognomonic CT finding of gastric varices is enhancing serpentine tubular structures in or around the gastric fundus/cardia wall. In the setting of portal hypertension (cirrhosis, splenomegaly, ascites), this finding is diagnostic. Intramural varices may be misinterpreted as wall thickening; however, tubular morphology and enhancement pattern distinguish from other causes of wall thickening.
Report Sentence
In the arterial phase, enhancing serpentine tubular structures in the gastric fundus/cardia wall and perigastric area are noted, consistent with gastric varices in the setting of portal hypertension.
Report Sentence
In the portal venous phase, gastric varices show prominent enhancement, with portal vein/splenic vein patency and portal hypertension findings evaluated.
Report Sentence
In the delayed phase, contrast washout in gastric varices is noted; active extravasation finding is not identified/is identified.
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On MRI, serpentine tubular structures with flow voids on T2W in the gastric fundus are noted, consistent with gastric varices.
Report Sentence
On Doppler US, multiple tubular structures with venous flow in the gastric fundus are noted consistent with gastric varices; portal vein diameter measures [X] mm.
Report Sentence
On barium study, lobulated filling defects in the gastric fundus are noted, with size change on distension consistent with gastric varices.
Criteria
Extension of esophageal varices along the lesser curvature to the gastric cardia; the most common type comprising 75% of gastric varices. Left gastric vein (coronary vein) is the afferent feeding vessel. Can be treated with endoscopic band ligation or sclerotherapy. Bleeding risk is similar to esophageal varices.
Distinct Features
Criteria
Extension of esophageal varices along the fundus. Short gastric veins and posterior gastric vein are afferent vessels. Rarer than GOV type 1 but bleeding risk is higher. Endoscopic treatment is difficult; cyanoacrylate injection or BRTO (balloon-occluded retrograde transvenous obliteration) is preferred.
Distinct Features
Criteria
Isolated fundal varices without esophageal varices. Splenic vein thrombosis (sinistral/left-sided portal hypertension) is the most common cause. Pancreatitis, pancreatic tumor, or hypercoagulability lead to splenic vein thrombosis. Follows the path: short gastric veins → fundal varices → splenorenal shunt. Splenectomy or splenic vein recanalization is considered for treatment. BRTO or TIPS are alternative treatment options.
Distinct Features
Distinguishing Feature
Distinguishing Feature
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Urgency
Management
Biopsy
Not NeededFollow-up
Gastric varices can cause life-threatening upper GI bleeding. Fundal varices bleed less frequently than esophageal varices but bleeding is more massive. TIPS, balloon-occluded retrograde transvenous obliteration (BRTO), or endoscopic treatment (cyanoacrylate) can be applied.