The fundal pile: bleeding gastric varices

Area of Science:

• Pediatric Gastroenterology
• Hepatology
• Surgical Gastroenterology

Background:

• Esophageal varices are a common cause of upper GI bleeding in children with portal hypertension.
• Gastric fundal varices present a greater challenge for nonoperative management, including sclerotherapy.
• Massive hemorrhage from gastric varices necessitates effective and rapid control strategies.

Purpose of the Study:

• To evaluate the efficacy of surgical underrunning for uncontrolled gastric variceal bleeding in children.
• To assess the role of sclerotherapy in managing recurrent variceal bleeding post-surgery.
• To highlight the increasing incidence and management challenges of gastric varices.

Main Methods:

• Retrospective analysis of 27 children undergoing injection sclerotherapy for bleeding varices since 1984.
• Focus on 9 children with gastric fundal varices, 5 of whom had failed nonoperative management.
• Emergency laparotomy with surgical underrunning for acute, uncontrolled bleeding.

Main Results:

• Surgical underrunning successfully controlled acute hemorrhage in 5 children with ruptured gastric fundal varices.
• Four of these patients were subsequently managed effectively with continued sclerotherapy.
• Complete obliteration of varices was achieved in 3 survivors, with no further life-threatening hemorrhage during 1-5 years follow-up.

Conclusions:

• Bleeding from gastric varices is more frequent and harder to control than previously thought.
• Surgical underrunning is a valuable option for initial control of severe gastric variceal hemorrhage.
• Sclerotherapy remains crucial for managing variceal recurrence after surgical intervention.