A case of huge gastric varices successfully treated with endoscopic injection sclerotherapy with occlusion of both supplying and draining veins with balloons

Gastric varices bleed less frequently but more severely than esophageal varices. Endoscopic treatment for gastric varices using sclerosants such as ethanol, ethanolamine oleate, and tissue adhesive agents has been reported, 1 Ono K Iwao T Sumino M Toyonaga A Tanikawa K Ethanolamine oleate versus butyl cyanoacrylate for bleeding gastric varices; a nonrandomized study. Endoscopy. 1995; 27: 349-354 Crossref PubMed Scopus (195) Google Scholar , 2 Ramond MJ Valla D Mosnier JF Degott C Bernuau J Rueff B et al. Successful endoscopic obturation of gastric varices with butyl cyanoacrylate. Hepatology. 1989; 10: 488-493 Crossref PubMed Scopus (141) Google Scholar , 3 Chun HJ Hyun JH A new method of endoscopic variceal ligation-injection sclerotherapy (EVLIS) for gastric varices. Korean J Intern Med. 1995; 10: 108-119 PubMed Google Scholar but no single effective method has yet been established. Other procedures for gastric varices such as surgical intervention, percutaneous transhepatic obliteration, transjugular intrahepatic portosystemic shunt (TIPS), and balloon-occluded retrograde transvenous obliteration (B-RTO) may be effective. 4 Stewart FW Shiffman M Isolated gastric varices associated with spontaneous splenorenal shunt. Dig Dis. 1996; 14: 209-210 Crossref PubMed Scopus (4) Google Scholar , 5 Lunderquist A Vang J Transhepatic catheterization and obliteration of the coronary vein in patients with portal hypertension and esophageal varices. N Engl J Med. 1974; 291: 646-649 Crossref PubMed Scopus (296) Google Scholar , 6 Kanagawa H Mima S Kouyama H Gotoh K Uchida T Okuda K Alimentary tract and pancreas—treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 1996; 11: 51-58 Crossref PubMed Scopus (429) Google Scholar , 7 Saeki H Hashizume M Ohta M Kishihara F Kawanaka H Sugimachi K The treatment of gastric varices by a balloon-occluded retrograde transvenous obliteration; a transjugular venous approach. Hepato-Gastroenterology. 1996; 43: 571-574 PubMed Google Scholar , 8 Chikamori F Shibuya S Takase Y Ozaki A Fukao K Transjugular retrograde obliteration for gastric varices. Abdom Imaging. 1996; 21: 299-303 Crossref PubMed Scopus (69) Google Scholar , 9 Koito K Namieno T Nagakawa T Morita K Balloon-occluded retrograde transvenous obliteration for gastric varices with gastrorenal or gastrocaval collaterals. Am J Roentgenol. 1996; 167: 1317-1320 Crossref PubMed Scopus (136) Google Scholar However, these procedures cannot always be performed because patients may have poor hepatic function or a hemorrhagic diathesis and often have hepatocellular carcinoma or sometimes gastric varices without an associated gastro-renal shunt. We therefore have tried to treat such varices with endoscopic injection sclerotherapy together with percutaneous transhepatic obliteration with a balloon catheter, and, if the gastric varices have a gastro-renal shunt, with obliteration of the shunt with another balloon catheter. This procedure has the advantage that sclerosant is placed with the targeted varices, and that it can be also used to treat gastric varices safely regardless of variations in portal anatomy. In the present case, we used this procedure for giant gastric varices 15 mm in diameter with the gastro-renal shunt and obtained complete embolization of the varices with use of minimal sclerosant.