Anatomy of Gastric Varix - basics

 

Gastrorenal shunts: 

Vast majority of IGVs are Gastro-renal shunts (and rarely Gastro-caval shunts). Gastro-renal shunts, at haemodynamic level, are truly spleno-(gastro)-renal shunts.

The Afferent to the GRS shunt is usually - either a LGV (left gastric vein) which is either the first branch of portal vein, or can arise from splenic vein just after the portal confluence, a posterior gastric vein (arising from Splenic vein) or Short gastric veins (arising from splenic vein). 

The GRS empties in to Left renal vein.

A true splenic-renal shunt, while will give rise to plenty of encephalopathy, but will not cause Gastric varix in its own right, as an SRS does not go through the GIT wall. 


One of the important concepts to understand, as highlighted in the figure below, is each Gastric varix, has 'True gastric varix' component, which is the intraluminal component (and the one, that is prone to bleeding), and often a larger, 'False gastric varix' or an Extra-luminal component (which is not prone to bleeding).

The FV, usually communicates with the True varix by one perforator vein or varix (shown by asterix below).

The afferent suppliers to Gastric varix system, are always extra-luminal, and do not enter gastric wall. 

The FV - communicates with both, the afferent suppliers, and efferent drainage, and communicates by one perforator to the intraluminal component of the varix.






dTIPS is usually not that useful in managing Gastric varix, as, gastric varix by definition is a shunt (natural TIPS). Infact, in those patients with low HVPG (highly effective gastric variceal shunt), the Gastric varix flow-rate is high, and particularly in these patients, TIPS appears to be in-effective. 

In Gastric varix, the portal pressure is not that much of a concern, but the flow-rate is an issue. Therefore, BRTO, BATO etc to obliterate the gastric varix are more effective management options.

Outstanding review on anatomy: Vascular AnatomyandtheMorphologicand Hemodynamic ClassificationsofGastricVarices and SpontaneousPortosystemicShuntsRelevant to theBRTOProcedure Wael E.A.Saad,MD,FSIR 

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