Pathophysiological management of gastric varices: From hemodynamics to targeted therapies

Gastric varices (GV) are a distinct and clinically challenging manifestation of portal hypertension characterized by complex vascular anatomy and unique hemodynamic behavior. Unlike esophageal varices (EV), GVs arise from interactions between afferent portal inflow, large variceal reservoirs, and spontaneous portosystemic shunts, resulting in a low-pressure, high-flow system that often responds poorly to conventional pressure-reducing therapies. Consequently, management strategies extrapolated from EV are frequently inadequate. Advances in endoscopic ultrasound (EUS), cross-sectional imaging, and interventional radiology have facilitated a paradigm shift toward a pathophysiology-driven approach. Contemporary evaluation integrates endoscopic classification based on anatomical location (Sarin), EUS for assessment of feeding vessels and flow dynamics, and computed tomography/magnetic resonance imaging for mapping afferent and efferent pathways using Kiyosue and Saad-Caldwell classifications. These frameworks enable hemodynamic triage into shunt-dominant, pressure-dominant, and complex patterns, which directly inform therapeutic selection. Endoscopic therapies, including cyanoacrylate injection and EUS-guided coil ± glue embolization, target the variceal reservoir and inflow, providing effective local control. Radiologic interventions address systemic hemodynamics, with retrograde transvenous obliteration (Balloon-occluded retrograde transvenous obliteration/plug-assisted retrograde transvenous obliteration/coil-assisted retrograde transvenous obliteration) preferred for shunt-dominant varices and transjugular intrahepatic portosystemic shunt for pressure-driven disease. Surgical options remain relevant in selected conditions such as left-sided portal hypertension. Clinical modifiers, including hepatic reserve, encephalopathy, ascites, and portal vein patency, further refine treatment decisions. A multidisciplinary, mechanism-based strategy is essential to optimize outcomes. Future research should focus on integrated classification systems and prospective comparative studies to establish standardized, individualized management algorithms.