Outcomes of Endoscopic Ultrasound guided Large Gastric Varices Obliteration (ELGVO study): A single centre real-world experience

Aims Gastric varices (GVs) are common in patients with portal hypertension, and are associated with severe bleeding with high mortality rates. Endoscopic management is often difficult, especially if GVs are large. Endoscopic ultrasound (EUS) has lately emerged as an effective therapeutic modality for GV obliteration. We demonstrate safety and efficacy outcomes of EUS guided obliteration of large GVs.

Methods In this single-center ambispective database, patients who underwent EUS guided obliteration for large GVs (> 10mm or carpeting the gastric fundus) were included. Target was the feeder to the varix wherever identifiable. Primary outcome was any GV bleed after procedure. Secondary outcomes were any variceal bleed and all-cause mortality. All procedures were performed by a single experienced operator

Results A total of 132 patients underwent ELGVO (84 prospectively assessed, 48 retrospective review of prospectively collected data). Median age was 51.5 years (14-74 years), with males constituting the majority (71%). Median size of varices was 30mm (12-84.5 mm). Most patients had cirrhosis (89.4%, 118 patients), with ethanol being commonest etiology (41%). Median baseline MELD and CTP were 11(6-37) and 6(5-14) respectively. Most patients had no prior bleed (NB:44.2%), while 42.7% were past bleeders(PB) and 13% had active bleeding(AB) at the time of presentation. Coils were used in combination with glue in 16 cases (12.2%). In most patients (97/132;74%) feeder to GV was targeted. Technical success was achieved in all cases. None of the patients showed any evidence of systemic/pulmonary embolism. Over a median follow-up of 272 days (0-1070 days), 7(5.3%) patients had GV bleed at median 195 days. Any variceal bleed was observed in 25(19%) cases over median of 90 days. Mortality was seen in 32(24.4%) cases at a median 282 days. Only one patient died of GV rebleed. GV bleed rates were significantly increased in AB(NB vs PB vs AB; 5.1% vs 3.5% vs 11.7%;p=0.02) and those with ethanol as etiology(ethanol vs others; 9.2% vs 2.5%;p=0.07). No significant difference in rebleed was seen when variceal size was stratified by quartiles (≤ 20 vs 21-30 vs 31-37 vs≥38; 8.5% vs 9% vs 3% vs 0%;p=0.27), use of coils (Glue vs Glue+coil; 51.7% vs 6.2%;p=0.66) and site targeted (Varix vs feeder; 8.5% vs 4.1%;p=0.58). All cause rebleed was higher in patients with alcohol related cirrhosis (34% vs 9%, P<0.01). Overall mortality rates were significantly higher among AB(NB vs PB vs AB; 22.4% vs 20.3% vs 47%;p=0.003), while variceal size, etiology, use of coils, and injection site were not significantly related.

Conclusions ELGVO is a safe and effective therapeutic modality, achieving high technical and clinical success rates with minimal complications. GV bleed and mortality rates were higher among active bleeders. Outcomes remain similar irrespective of varix size, obliteration with/without coils, and whether the target was varix or feeder.

Publication History

Article published online:
27 March 2025