Variceal Glue Injection
Gastric variceal bleeding (GVB) accounts for 10–15% of all variceal bleeds. Following general supportive measures (eg, resuscitation, terlipressin and antibiotics), the endoscopic management of acute GVB is difficult in the light of active bleeding or rebleeding as often technically challenging given gastric variceal anatomical and physiological considerations. Although successful haemostasis and obliteration of gastric varices are reported with VBL and certain sclerosing agents (eg, absolute alcohol), results are variable if not typically poor.Where primary haemostasis was not achieved and/or later re-bled, BT is necessary to bridge the patient to more definitive intervention such as TIPS, surgical shunt and, if appropriate, transplantation. If locally available, and in appropriate patients (eg, absence of significant HE episode) early TIPS placement is known to arrest AVB and reduce rebleeding rates from oesophageal and gastric varices,by reducing portal pressure as AVB is unlikely if hepatic vein pressure gradient (HVPG) is ≤12 mm Hg,Even with successful TIPS (reducing HVPG ≤12 mm Hg), gastric varices have a tendency to bleed despite low portal pressures. However, over recent years, there has been the increasing and successful application of cyanoacrylate glue therapy for refractory oesophageal and gastric AVB leading to immediate haemostasis and variceal obliteration. Based on published evidence, glue is more effective than band ligation for gastric varices.