Gastric varices are swollen, enlarged veins in the lining of the stomach that develop when blood pressure in the portal vein (the major vessel carrying blood to the liver) becomes abnormally high. They affect roughly 17% to 25% of people with portal hypertension and, while they bleed less frequently than similar veins in the esophagus, bleeding episodes can be severe and life-threatening.
How Gastric Varices Form
Blood from the digestive organs normally flows through the portal vein into the liver for filtering. When the liver is scarred or blocked, that flow backs up, raising pressure throughout the portal system. The body responds by rerouting blood through smaller veins that weren’t designed to handle the volume. In the stomach, these detour veins swell beneath the inner lining, forming varices.
Cirrhosis is the most common underlying cause, but anything that raises portal pressure or blocks the splenic vein can trigger gastric varices. That includes blood clots in the splenic or portal veins, chronic pancreatitis, pancreatic tumors, and pancreatic pseudocysts. When a splenic vein blockage is the culprit, the condition is sometimes called sinistral (left-sided) portal hypertension. In these cases, blood that would normally drain through the splenic vein is forced through small gastric veins instead, inflating them into varices in the upper portion of the stomach known as the fundus.
Types and Locations
Doctors classify gastric varices using a system called the Sarin classification, which is based on where the swollen veins appear during an endoscopy. The two broad categories are gastroesophageal varices (which connect to varicose veins in the esophagus) and isolated gastric varices (which exist only in the stomach).
- GOV1: The most common type. These varices extend from the esophagus down along the lesser curvature of the stomach, the shorter inner curve.
- GOV2: These also connect to esophageal varices but extend into the fundus, the dome-shaped upper portion of the stomach.
- IGV1 (fundal varices): Isolated varices found only in the fundus, with no esophageal involvement. These are strongly associated with splenic vein problems.
- IGV2: Rare, ectopic varices that can appear anywhere else in the stomach.
The type matters because it influences both the risk of bleeding and which treatments work best. GOV2 and IGV1 varices, located in the fundus, tend to bleed more heavily and are harder to treat endoscopically than GOV1 varices along the lesser curvature.
Symptoms and Bleeding Risk
Most gastric varices cause no symptoms at all. Unlike esophageal varices, they uncommonly present with sudden bleeding as the first sign. They’re usually discovered during a routine upper endoscopy performed as screening in people already known to have portal hypertension or cirrhosis. About 19% of patients are first diagnosed because of a bleeding episode.
When bleeding does occur, it can be massive. Each episode of variceal hemorrhage carries a 15% to 40% mortality rate depending on how advanced the underlying liver disease is. In one study following patients over time, roughly 31% experienced at least one variceal hemorrhage. Several features visible during endoscopy signal a higher chance of bleeding: red spots on the surface of the varix (glossy, thin-walled areas of redness), larger varix size, and red wale marks. People with more advanced liver disease, particularly those with significant liver dysfunction, face the greatest risk.
How They’re Diagnosed
Upper endoscopy is the primary tool. A flexible camera is passed through the mouth into the stomach, giving doctors a direct look at the veins. They assess the shape (tortuous, nodular, or tumor-like), location, and color. A white varix is generally lower risk; a red one, especially with red spots, raises concern.
Endoscopic ultrasound adds another layer of detail. It can visualize not just the varices themselves but also the feeding veins and collateral vessels beneath the stomach wall. Doppler imaging during this procedure confirms whether blood is actively flowing through the varix, which helps with treatment planning and predicting re-bleeding risk.
CT scans with contrast are used to map the full vein anatomy, which becomes critical when planning procedures. Imaging can trace where the blood is draining. In 80% to 85% of isolated gastric varices, blood flows downward through a natural shunt between the stomach area and the left kidney vein. In another 10% to 15%, the drainage route runs to the large vein returning blood to the heart. Knowing the exact plumbing determines which interventional procedures are possible.
Preventing a First Bleed
For people with gastric varices who have never bled, the goal is to keep it that way. The most recent international consensus guidelines (Baveno VII) recommend a class of blood pressure medications called non-selective beta-blockers as the first-line approach. These drugs lower pressure in the portal system and have an additional benefit: in people with compensated cirrhosis, they help prevent other complications of liver disease beyond just variceal bleeding.
One study found that injecting a tissue glue directly into the varix was more effective than beta-blockers at preventing a first bleed from fundal or GOV2 varices, but survival rates were the same. Because beta-blockers offer broader protective benefits, guidelines still favor them as the starting point. If someone can’t tolerate beta-blockers, endoscopic band ligation (placing tiny rubber bands around the varix to cut off blood flow) is an alternative for high-risk varices.
More invasive procedures like TIPS (a shunt placed inside the liver to relieve portal pressure) or BRTO (a technique that blocks the drainage vein behind the varices) are not recommended for preventing a first bleed in people with otherwise stable liver function.
Treating Active Bleeding
When gastric varices do bleed, the treatment approach differs from esophageal varices. Band ligation, the standard for esophageal bleeding, doesn’t work as well in the stomach. Instead, the most widely used endoscopic treatment is tissue glue injection. A fast-acting adhesive is injected directly into the bleeding varix through the endoscope. On contact with blood, the glue hardens within 5 to 10 seconds, sealing the vessel. This achieves initial hemostasis in about 99% of cases, and after multiple treatment sessions, complete obliteration of the varices is possible in over 95% of patients.
TIPS is another highly effective option, controlling initial bleeding in about 90% of cases with re-bleeding rates around 15%. A radiologist threads a catheter through the neck vein into the liver and creates a new channel that diverts portal blood flow, relieving the pressure that feeds the varices. While TIPS and glue injection have comparable success at stopping active bleeding and similar mortality rates, TIPS results in significantly less re-bleeding over time.
BRTO for Fundal Varices
Balloon-occluded retrograde transvenous obliteration, or BRTO, is a specialized procedure primarily used for fundal varices (IGV1) that drain through a natural shunt to the kidney vein. A catheter is guided through the groin or neck vein into this shunt, a balloon is inflated to block the outflow, and a sclerosing agent is injected to destroy the varices from the drainage side.
Not everyone is a candidate. The procedure requires a suitable shunt to exist, and it’s typically not an option for people with large liver tumors or significant fluid buildup in the abdomen. Because BRTO closes off a natural pressure-relief valve, it redirects blood back toward the liver and portal system, which can worsen esophageal varices or increase fluid retention in some patients. Treatment may be staged across multiple sessions to limit the amount of sclerosing agent used and reduce the risk of kidney complications.
BRTO has become particularly well established in Japan, where it’s often the preferred approach for gastric varices with a drainable shunt. Its role continues to expand in Western practice as well, especially for patients who aren’t good candidates for TIPS.
Preventing Re-Bleeding
After a first bleed, the priority shifts to making sure it doesn’t happen again. Non-selective beta-blockers remain the foundation of long-term prevention. For people who continue to bleed despite medication and endoscopic treatment, TIPS should be considered. In cases where bleeding from the stomach lining persists and the patient is becoming dependent on blood transfusions, TIPS offers the most definitive pressure reduction.
Endoscopic options for recurrent bleeding include repeat glue injection sessions and, for more diffuse stomach lining bleeding, techniques like argon plasma coagulation or hemostatic powder applied through the endoscope. The choice depends on the type of varices, the underlying cause, the patient’s liver function, and the vascular anatomy mapped out on imaging.