Patients with end-stage liver disease (cirrhosis) or patients with other causes of portal hypertension can develop abnormal blood vessels along the wall of the gut. 

Most commonly, these abnormal blood vessels, called varices, develop in the lower esophagus. The standard therapy for the treatment of varices in the esophagus that have bled or that are at risk of bleeding involves the use of rubber bands placed around the varices to squeeze them and cause them to clot.

 Varices may also develop in the stomach in up to 20% of people with portal hypertension. Though varices are less common in the stomach, they are potentially deadlier if they start to bleed. 



Because varices in the stomach are typically deeper within the stomach wall compared to the esophagus, rubber band therapy is inappropriate for isolated gastric varices since the entire vessel may not be captured within the rubber band. Rubber band therapy may thus result in catastrophic bleeding as the rubber band sloughs off.  

Instead, we treat varices in the stomach with a technique called glue-coil embolization. 

This technique was invented here at IES by Dr. Binmoeller and has subsequently been adapted at expert centers worldwide as first-line therapy for gastric varices. 

Prior to the development of this therapy, patients frequently needed to have something called a TIPS created (Transjugular Intrahepatic Portosystemic Shunt). This procedure reduces pressure in varices to stop or prevent bleeding by shunting blood away from them. While this procedure can be successful for the treatment of varices, it risks decompensation of the liver and can cause the development of confusion due to hepatic encephalopathy.



During this procedure, endoscopy is performed using a scope with an ultrasound probe at its end. While the patient is sedated, the scope is advanced through the mouth into the patient’s stomach. There, an ultrasound examination is used to identify the size and location of gastric varices. 

Frequently, multiple gastric varices are present but the main blood vessel supplying the gastric varices can be identified by ultrasound. Under real-time ultrasound imaging, a needle is then introduced into the stomach and used to inject a material equivalent to superglue into the gastric varix blood vessel. 

The major risk of glue injection alone is that the glue can flow through the bloodstream to a different location before it hardens, causing a clot in an unwanted and potentially dangerous location such as the lungs, or in some cases, the brain.

To prevent the glue from being carried away in the blood before hardening, what we first inject into the blood vessel is a metal coil. The coil has wool-like fibers on it, and this structure acts as a scaffold for the glue to stick to so that it hardens at the intended location within the gastric varices. 

The use of coil injection prior to glue injection was pioneered here at IES. Endoscopic ultrasound-guided glue-coil injection is very effective at causing gastric varices to clot off completely to stop and prevent life-threatening bleeding.

After the initial treatment, patients will typically have a repeat endoscopy in 1-3 months in order to ensure that the gastric varices have been completely destroyed.

A. Gastric varices (abnormal blood vessels in stomach at risk of life-threatening bleeding).
B. Coil and glue delivery into abnormal blood to cause clot in the blood vessel.
C. Post-treatment – coil and glue gradually get pushed out of the wall of the stomach after the blood vessels have clotted.
D. Gastric varices resolved.