Background:

Gastric varices (GV) are an uncommon but life-threatening cause of gastrointestinal bleeding in patients with portal hypertension (PH). Their management using standard methods remains challenging, especially in patients with hepatic encephalopathy (HE), for whom transjugular intrahepatic portosystemic shunt (TIPS) may be contraindicated, requiring alternative approaches. We report a case of a high-risk, type 1 isolated GV (IGV1) successfully managed with endoscopic ultrasound (EUS)-guided coil embolization, resulting in subsequent improvement in HE.

Case Presentation and Management:

A 72-year-old male with dysmetabolic cirrhosis and overt HE was referred for surveillance of esophageal varices (EV). Esophagogastroduodenoscopy revealed F2-grade EV with haematocystic spots, treated with band ligation, and a submucosal fundic bulge consistent with IGV1, further confirmed by EUS. To assess the degree of PH, an EUS-guided portal pressure gradient measurement was performed, yielding a value of 16 mmHg. Due to persistent overt HE, TIPS was considered unsuitable. EUS-guided coil embolization was performed as primary prophylaxis, targeting the gastro-renal shunt.

Outcomes:

The procedure resulted in the disappearance of GV and improvement in HE, documented one month later by an increase in the Animal Naming Test score from 6 to 17, along with a decrease in plasma ammonia levels from 105 to 68 μmol/L.

Conclusions:

EUS-guided embolization of GV is emerging as an effective alternative to conventional treatments, particularly for patients unsuitable for TIPS. Beyond achieving effective variceal control, shunt embolization may contribute to improvement in pre-existing HE by reducing portosystemic diversion. Further studies are needed to assess the long-term outcomes of this approach.