cirrhosis is present, there may be coagulopathy manifested by a prolonged INR; both of these may worsen the bleeding from gastric varices. In rare cases, gastric varices are caused by splenic vein occlusion as a result of the mass effect of slow-growing pancreatic neuroendocrine tumors. Diagnosis The diagnosis of gastric varices is often made at the time of upper endoscopy. Classification The Sarin classification of gastric varices identifies four different anatomical types of gastric varices, which differ in terms of treatment modalities. Treatment Initial treatment of bleeding from gastric varices focuses on resuscitation, much as with esophageal varices. This includes administration of fluids, blood products, and antibiotics. Another treatment for gastric varices is injection of the varices with cyanoacrylate, first described by German surgeon Nib Soehendra and colleagues in 1986. The results from two randomized trials comparing band ligation vs cyanoacrylate suggests that endoscopic injection of cyanoacrylate, known as gastric variceal obliteration or GVO is superior to band ligation in preventing rebleeding rates. Cyanoacrylate, a common component in 'super glue' is often mixed 1:1 with lipiodol to prevent polymerization in the endoscopy delivery optics, and to show on radiographic imaging. GVO is usually performed in specialized therapeutic endoscopy centers. Complications include sepsis, embolization of glue, and obstruction from polymerization in the lumen of the stomach. Other techniques for refractory bleeding include: Transjugular intrahepatic portosystemic shunts (TIPS) Balloon occluded retrograde transvenous obliteration techniques (BORTO) Coil-Assisted Retrograde Transvenous Obliteration (CARTO) Gastric variceal ligation, although this modality is falling out of favour Intra-gastric balloon tamponade as a bridge to further therapy a caveat is that a larger balloon is required to occupy the fundus of the stomach where gastric varices commonly occur Liver transplantation See also Gastric antral vascular ectasia References External links Stomach disorders Diseases of veins, lymphatic vessels and lymph nodes