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__NOTOC__
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{{Gastrointestinal varices}}
{{Gastrointestinal varices}}
{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{HK}}


==Overview==
==Overview==
Gastrointestinal varices may be further classified into [[esophageal]] and [[gastric]] varices. [[Gastrointestinal varices|Esophageal varices]] may be further divided according to various classification systems such as the Dagradi classification, Conn's classification, Pachquet classification, Westaby classification, Soehendra classification and Cales classification. [[Gastrointestinal varices|Gastric varices]] may be classified according to Hoskins and Johnson’s classification, Mathur’s classification, Hashizume classification and Sarin's classification system. These classificatication systems are based on morphological features, [[anatomical]] location, size and color of the varices.


==Classification==
==Classification==


=== Classification of esophageal varices ===
=== Classification of esophageal varices ===
The following table outlines the major classification schemes for esophageal varices, based on grades:
The following table outlines the major classification schemes for esophageal varices, based on grades, taking into account morphological features, size and [[anatomical]] location:<ref name="pmid14884140">{{cite journal |vauthors=BUTLER H |title=The veins of the oesophagus |journal=Thorax |volume=6 |issue=3 |pages=276–96 |year=1951 |pmid=14884140 |pmc=1018380 |doi= |url=}}</ref><ref name="pmid4190630">{{cite journal |vauthors=Sternlieb I, Scheinberg IH, Walshe JM |title=Bleeding oesophageal varices in patients with Wilson's disease |journal=Lancet |volume=1 |issue=7648 |pages=638–41 |year=1970 |pmid=4190630 |doi= |url=}}</ref><ref name="pmid14109008">{{cite journal |vauthors=BRICK IB, PALMER ED |title=ONE THOUSAND CASES OF PORTAL CIRRHOSIS OF THE LIVER. IMPLICATIONS OF ESOPHAGEAL VARICES AND THEIR MANAGEMENT |journal=Arch. Intern. Med. |volume=113 |issue= |pages=501–11 |year=1964 |pmid=14109008 |doi= |url=}}</ref><ref name="pmid5295832">{{cite journal |vauthors=Dagradi AE, Stempien SJ, Owens LK |title=Bleeding esophagogastric varices. An endoscopic study of 50 cases |journal=Arch Surg |volume=92 |issue=6 |pages=944–7 |year=1966 |pmid=5295832 |doi= |url=}}</ref><ref name="pmid6066657">{{cite journal |vauthors=Conn HO |title=Ammonia tolerance in the diagnosis of esophageal varices. A comparison of endoscopic, radiologic, and biochemical techniques |journal=J. Lab. Clin. Med. |volume=70 |issue=3 |pages=442–51 |year=1967 |pmid=6066657 |doi= |url=}}</ref><ref name="pmid7373958">{{cite journal |vauthors= |title=The general rules for recording endoscopic findings on esophageal varices |journal=Jpn J Surg |volume=10 |issue=1 |pages=84–7 |year=1980 |pmid=7373958 |doi= |url=}}</ref><ref name="pmid6975734">{{cite journal |vauthors=Beppu K, Inokuchi K, Koyanagi N, Nakayama S, Sakata H, Kitano S, Kobayashi M |title=Prediction of variceal hemorrhage by esophageal endoscopy |journal=Gastrointest. Endosc. |volume=27 |issue=4 |pages=213–8 |year=1981 |pmid=6975734 |doi= |url=}}</ref><ref name="pmid6352448">{{cite journal |vauthors=Westaby D, Macdougall BR, Melia W, Theodossi A, Williams R |title=A prospective randomized study of two sclerotherapy techniques for esophageal varices |journal=Hepatology |volume=3 |issue=5 |pages=681–4 |year=1983 |pmid=6352448 |doi= |url=}}</ref><ref name="pmid3262200">{{cite journal |vauthors= |title=Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study |journal=N. Engl. J. Med. |volume=319 |issue=15 |pages=983–9 |year=1988 |pmid=3262200 |doi=10.1056/NEJM198810133191505 |url=}}</ref><ref name="pmid3494762">{{cite journal |vauthors= |title=Reliability of endoscopy in the assessment of variceal features. The Italian Liver Cirrhosis Project |journal=J. Hepatol. |volume=4 |issue=1 |pages=93–8 |year=1987 |pmid=3494762 |doi= |url=}}</ref><ref name="pmid2293575">{{cite journal |vauthors=Calès P, Zabotto B, Meskens C, Caucanas JP, Vinel JP, Desmorat H, Fermanian J, Pascal JP |title=Gastroesophageal endoscopic features in cirrhosis. Observer variability, interassociations, and relationship to hepatic dysfunction |journal=Gastroenterology |volume=98 |issue=1 |pages=156–62 |year=1990 |pmid=2293575 |doi= |url=}}</ref><ref name="pmid26047908">{{cite journal |vauthors=de Franchis R |title=Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension |journal=J. Hepatol. |volume=63 |issue=3 |pages=743–52 |year=2015 |pmid=26047908 |doi=10.1016/j.jhep.2015.05.022 |url=}}</ref><ref name="pmid8903373">{{cite journal |vauthors=Zoli M, Merkel C, Magalotti D, Marchesini G, Gatta A, Pisi E |title=Evaluation of a new endoscopic index to predict first bleeding from the upper gastrointestinal tract in patients with cirrhosis |journal=Hepatology |volume=24 |issue=5 |pages=1047–52 |year=1996 |pmid=8903373 |doi=10.1053/jhep.1996.v24.pm0008903373 |url=}}</ref>


{| class="wikitable"
{| class="wikitable"
!Classification system
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Classification system
!Grade
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Grade
!Interpretation of grade
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Interpretation of grade
|-
|-
| rowspan="5" |'''Dagradi classification'''
| rowspan="5" |'''Dagradi classification'''
Line 19: Line 20:
|
|
* Blue or red discoloration of varices
* Blue or red discoloration of varices
* Become prominent on compression of esophageal wall by esophagoscope
* Become prominent on compression of [[esophageal]] wall by [[Endoscope|esophagoscope]]
* Linear/sigmoid shaped
* Linear/sigmoid shaped
* < 2 mm in diameter
* < 2 mm in diameter
Line 28: Line 29:
* 2–3 mm in diameter
* 2–3 mm in diameter
* Mildly tortuous or straight
* Mildly tortuous or straight
* Elevated above the surface or the relaxed oesophagus
* Elevated above the surface or the relaxed [[esophagus]]
|-
|-
|3
|3
|
|
* Prominently elevated bluish veins
* Prominently elevated bluish [[veins]]
* 3–4 mm in diameter
* 3–4 mm in diameter
* Straight or tortuous
* Straight or [[tortuous]]
|-
|-
|4
|4
|
|
* Bluish varices
* Bluish varices
* > 4 mm in diameter, which completely surround the oesophageal lumen and almost meet in the mid-lumen
* > 4 mm in diameter, which completely surround the [[Esophagus|esophageal lumen]] and almost meet in the mid-lumen
* Tortuous
* [[Tortuous]]
* Closely packed around the wall  
* Closely packed around the wall  
* With or without mucosal cover
* With or without [[mucosal]] cover
|-
|-
|5
|5
|
|
* Grape-like appearance
* Grape-like appearance
* Occlude the lumen of the advancing oesophagoscope
* Occlude the lumen of the advancing [[Endoscope|esophagoscope]]
* Presence of small, cherry-red varices on top of a base of bluish varices
* Presence of small, cherry-red varices on top of a base of bluish varices
|-
|-
Line 53: Line 54:
|I
|I
|
|
* Varices visible during only one phase of [[respiration]]
|-
|-
|II
|II
|
|
* Varices visible during both phases of [[respiration]]
|-
|-
|III
|III
|
|
* 3-6 mm in diameter
|-
|-
|IV
|IV
|
|
* > 6 mm in diameter
|-
|-
| rowspan="4" |'''Paquet’s classification'''
| rowspan="4" |'''Paquet’s classification'''
|I
|I
|
|
* [[Capillaries|Microcapillaries]] located in :
** Distal [[esophagus]]
** [[Esophagus|Esophago]]-[[gastric]] junction
|-
|-
|II
|II
|
|
* 1-2 variceal [[Blood vessel|vessels]] located in the distal [[esophagus]]
|-
|-
|III
|III
|
|
* Medium-sized varices of any number
|-
|-
|IV
|IV
|
|
* Large-sized varices in any part of [[esophagus]]
|-
|-
| rowspan="4" |'''Westaby classification'''
| rowspan="3" |'''Westaby classification'''
|1
|1
|
|
*  Varices protruded above [[mucosa]]
* May be depressed with insufflations.
|-
|-
|2
|2
|
|
*  Varices covering <50% of the [[lumen]]
|-
|-
|3
|3
|
|
|-
* Varices covering >50% of the [[lumen]]
|4
|
|-
|-
| rowspan="4" |'''Soehendra classification'''
| rowspan="4" |'''Soehendra classification'''
|I
|I
|
|
* Mild dilatation
* Diameter <2 mm
* More prominent on flexing the [[neck]] forward
|-
|-
|II
|II
|
|
* Moderate dilatation
* [[Tortuous]]
* Diameter 3–4 mm
* Located in the lower part of the [[esophagus]]
|-
|-
|III
|III
|
|
* Total dilatation
* Diameter >4 mm
* Thin-walled
* Varices superimposed on varices
* Located in the [[gastric]] [[Fundus of stomach|fundus]]
|-
|-
|IV
|IV
|
|
* Total dilatation
* Found in the entire [[esophagus]]
* Simultaneous presence of gastric or duodenal varices
|-
|-
| rowspan="3" |'''Calès classification'''
| rowspan="3" |'''Calès classification'''
|1
|1
|
|
*  Varices flattened by insufflations
|-
|2
|
*  Varices not flattened by insufflations
|-
|3
|
* Confluent esophageal varices not flattened by insufflations
|}
=== Classification of gastric varices ===
The following table outlines the major classification systems adapted for classifying gastric varices:<ref name="pmid2340395">{{cite journal |vauthors=Mathur SK, Dalvi AN, Someshwar V, Supe AN, Ramakantan R |title=Endoscopic and radiological appraisal of gastric varices |journal=Br J Surg |volume=77 |issue=4 |pages=432–5 |year=1990 |pmid=2340395 |doi= |url=}}</ref><ref name="pmid3349325">{{cite journal |vauthors=Hosking SW, Johnson AG |title=Gastric varices: a proposed classification leading to management |journal=Br J Surg |volume=75 |issue=3 |pages=195–6 |year=1988 |pmid=3349325 |doi= |url=}}</ref><ref name="pmid2365213">{{cite journal |vauthors=Hashizume M, Kitano S, Yamaga H, Koyanagi N, Sugimachi K |title=Endoscopic classification of gastric varices |journal=Gastrointest. Endosc. |volume=36 |issue=3 |pages=276–80 |year=1990 |pmid=2365213 |doi= |url=}}</ref><ref name="pmid1446890">{{cite journal |vauthors=Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK |title=Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients |journal=Hepatology |volume=16 |issue=6 |pages=1343–9 |year=1992 |pmid=1446890 |doi= |url=}}</ref><ref name="pmid11928080">{{cite journal |vauthors=Arakawa M, Masuzaki T, Okuda K |title=Pathomorphology of esophageal and gastric varices |journal=Semin. Liver Dis. |volume=22 |issue=1 |pages=73–82 |year=2002 |pmid=11928080 |doi=10.1055/s-2002-23208 |url=}}</ref><ref name="pmid11323583">{{cite journal |vauthors=Iwase H, Maeda O, Shimada M, Tsuzuki T, Peek RM, Nishio Y, Ando T, Ina K, Kusugami K |title=Endoscopic ablation with cyanoacrylate glue for isolated gastric variceal bleeding |journal=Gastrointest. Endosc. |volume=53 |issue=6 |pages=585–92 |year=2001 |pmid=11323583 |doi= |url=}}</ref>
{| class="wikitable"
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Classification system
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Grade
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Interpretation of grade
|-
| rowspan="3" |Hoskins and Johnson’s classification
|1
|
* Extension of esophageal varices across the [[Squamous epithelium|squamo]]-[[Columnar epithelia|columnar]] junction
|-
|-
|2
|2
|
|
*  Varices located in [[Fundus (stomach)|gastric fundus]]
* Overlap with esophageal varices in the [[esophagus]] at cardiac end
|-
|-
|3
|3
|
|
* Gastric varices in [[Fundus (stomach)|gastric fundus]] or body
* No esophageal varices
|-
| rowspan="5" |Mathur’s classification
|1
|
* Esophageal varices with [[Lesser curvature of the stomach|lesser curvature]] varices
|-
|2
|
* Esophageal varices with gastric fundal varices
* 2a – Subcardiac
* 2b – Diffuse fundal
|-
|3
|
* Isolated fundal varix
* 3a – Secondary to [[splenic vein thrombosis]]
* 3b – Secondary to generalized [[portal hypertension]]
|-
|4
|
* [[Lesser curvature]] gastric varices
* Esophageal varices along with varices located in the [[Fundus (stomach)|gastric fundus]]
|-
|5
|
* Varices in the [[Antrum|gastric antrum]]
|-
| rowspan="3" |Hashizume’s classification
|Form
|
* Three forms:
** F1: [[Tortuous]]
** F2: Nodular
** F3: Tumorous
|-
|Location
|
* Five common locations:
** La: [[Anterior]]
** Lp: [[Posterior]]
** Ll: [[Lesser curvature of the stomach]]
** L: [[Greater curvature of the stomach|Greater curvature cardiac of the stomach]]
** Lf: [[Fundus (stomach)|Fundic areas of the stomach]]
|-
|Color
|
* Three colors:
** Cr: Red
** Cw: White
** RCS: Thin-walled focal redness on the varix as red colored spot
|-
| rowspan="4" |Sarin’s classification
|Gastro-esophageal type 1
|
* Esophageal varices spreading into the [[lesser curvature of the stomach]]
|-
|Gastro-esophageal type 2
|
* Esophageal varices spreading into the [[greater curvature of the stomach]]
|-
|Isolated gastric type 1
|
* Varices in the [[Fundus (stomach)|gastric fundus]] and [[cardia]] without esophageal varices
|-
|Isolated gastric type 2
|
* Varices outside of [[Cardia|cardio]]-[[Fundus (stomach)|fundal]] region or first part of [[duodenum]]
|}
|}


Latest revision as of 13:56, 24 January 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Overview

Gastrointestinal varices may be further classified into esophageal and gastric varices. Esophageal varices may be further divided according to various classification systems such as the Dagradi classification, Conn's classification, Pachquet classification, Westaby classification, Soehendra classification and Cales classification. Gastric varices may be classified according to Hoskins and Johnson’s classification, Mathur’s classification, Hashizume classification and Sarin's classification system. These classificatication systems are based on morphological features, anatomical location, size and color of the varices.

Classification

Classification of esophageal varices

The following table outlines the major classification schemes for esophageal varices, based on grades, taking into account morphological features, size and anatomical location:[1][2][3][4][5][6][7][8][9][10][11][12][13]

Classification system Grade Interpretation of grade
Dagradi classification 1
  • Blue or red discoloration of varices
  • Become prominent on compression of esophageal wall by esophagoscope
  • Linear/sigmoid shaped
  • < 2 mm in diameter
2
  • Bluish in color
  • 2–3 mm in diameter
  • Mildly tortuous or straight
  • Elevated above the surface or the relaxed esophagus
3
  • Prominently elevated bluish veins
  • 3–4 mm in diameter
  • Straight or tortuous
4
  • Bluish varices
  • > 4 mm in diameter, which completely surround the esophageal lumen and almost meet in the mid-lumen
  • Tortuous
  • Closely packed around the wall
  • With or without mucosal cover
5
  • Grape-like appearance
  • Occlude the lumen of the advancing esophagoscope
  • Presence of small, cherry-red varices on top of a base of bluish varices
Conn's classification I
II
III
  • 3-6 mm in diameter
IV
  • > 6 mm in diameter
Paquet’s classification I
II
III
  • Medium-sized varices of any number
IV
Westaby classification 1
  •  Varices protruded above mucosa
  • May be depressed with insufflations.
2
  •  Varices covering <50% of the lumen
3
  • Varices covering >50% of the lumen
Soehendra classification I
  • Mild dilatation
  • Diameter <2 mm
  • More prominent on flexing the neck forward
II
  • Moderate dilatation
  • Tortuous
  • Diameter 3–4 mm
  • Located in the lower part of the esophagus
III
  • Total dilatation
  • Diameter >4 mm
  • Thin-walled
  • Varices superimposed on varices
  • Located in the gastric fundus
IV
  • Total dilatation
  • Found in the entire esophagus
  • Simultaneous presence of gastric or duodenal varices
Calès classification 1
  •  Varices flattened by insufflations
2
  •  Varices not flattened by insufflations
3
  • Confluent esophageal varices not flattened by insufflations

Classification of gastric varices

The following table outlines the major classification systems adapted for classifying gastric varices:[14][15][16][17][18][19]

Classification system Grade Interpretation of grade
Hoskins and Johnson’s classification 1
2
3
Mathur’s classification 1
2
  • Esophageal varices with gastric fundal varices
  • 2a – Subcardiac
  • 2b – Diffuse fundal
3
4
5
Hashizume’s classification Form
  • Three forms:
Location
Color
  • Three colors:
    • Cr: Red
    • Cw: White
    • RCS: Thin-walled focal redness on the varix as red colored spot
Sarin’s classification Gastro-esophageal type 1
Gastro-esophageal type 2
Isolated gastric type 1
Isolated gastric type 2

References

  1. ↑ BUTLER H (1951). "The veins of the oesophagus". Thorax. 6 (3): 276–96. PMC 1018380. PMID 14884140.
  2. ↑ Sternlieb I, Scheinberg IH, Walshe JM (1970). "Bleeding oesophageal varices in patients with Wilson's disease". Lancet. 1 (7648): 638–41. PMID 4190630.
  3. ↑ BRICK IB, PALMER ED (1964). "ONE THOUSAND CASES OF PORTAL CIRRHOSIS OF THE LIVER. IMPLICATIONS OF ESOPHAGEAL VARICES AND THEIR MANAGEMENT". Arch. Intern. Med. 113: 501–11. PMID 14109008.
  4. ↑ Dagradi AE, Stempien SJ, Owens LK (1966). "Bleeding esophagogastric varices. An endoscopic study of 50 cases". Arch Surg. 92 (6): 944–7. PMID 5295832.
  5. ↑ Conn HO (1967). "Ammonia tolerance in the diagnosis of esophageal varices. A comparison of endoscopic, radiologic, and biochemical techniques". J. Lab. Clin. Med. 70 (3): 442–51. PMID 6066657.
  6. ↑ "The general rules for recording endoscopic findings on esophageal varices". Jpn J Surg. 10 (1): 84–7. 1980. PMID 7373958.
  7. ↑ Beppu K, Inokuchi K, Koyanagi N, Nakayama S, Sakata H, Kitano S, Kobayashi M (1981). "Prediction of variceal hemorrhage by esophageal endoscopy". Gastrointest. Endosc. 27 (4): 213–8. PMID 6975734.
  8. ↑ Westaby D, Macdougall BR, Melia W, Theodossi A, Williams R (1983). "A prospective randomized study of two sclerotherapy techniques for esophageal varices". Hepatology. 3 (5): 681–4. PMID 6352448.
  9. ↑ "Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study". N. Engl. J. Med. 319 (15): 983–9. 1988. doi:10.1056/NEJM198810133191505. PMID 3262200.
  10. ↑ "Reliability of endoscopy in the assessment of variceal features. The Italian Liver Cirrhosis Project". J. Hepatol. 4 (1): 93–8. 1987. PMID 3494762.
  11. ↑ Calès P, Zabotto B, Meskens C, Caucanas JP, Vinel JP, Desmorat H, Fermanian J, Pascal JP (1990). "Gastroesophageal endoscopic features in cirrhosis. Observer variability, interassociations, and relationship to hepatic dysfunction". Gastroenterology. 98 (1): 156–62. PMID 2293575.
  12. ↑ de Franchis R (2015). "Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension". J. Hepatol. 63 (3): 743–52. doi:10.1016/j.jhep.2015.05.022. PMID 26047908.
  13. ↑ Zoli M, Merkel C, Magalotti D, Marchesini G, Gatta A, Pisi E (1996). "Evaluation of a new endoscopic index to predict first bleeding from the upper gastrointestinal tract in patients with cirrhosis". Hepatology. 24 (5): 1047–52. doi:10.1053/jhep.1996.v24.pm0008903373. PMID 8903373.
  14. ↑ Mathur SK, Dalvi AN, Someshwar V, Supe AN, Ramakantan R (1990). "Endoscopic and radiological appraisal of gastric varices". Br J Surg. 77 (4): 432–5. PMID 2340395.
  15. ↑ Hosking SW, Johnson AG (1988). "Gastric varices: a proposed classification leading to management". Br J Surg. 75 (3): 195–6. PMID 3349325.
  16. ↑ Hashizume M, Kitano S, Yamaga H, Koyanagi N, Sugimachi K (1990). "Endoscopic classification of gastric varices". Gastrointest. Endosc. 36 (3): 276–80. PMID 2365213.
  17. ↑ Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK (1992). "Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients". Hepatology. 16 (6): 1343–9. PMID 1446890.
  18. ↑ Arakawa M, Masuzaki T, Okuda K (2002). "Pathomorphology of esophageal and gastric varices". Semin. Liver Dis. 22 (1): 73–82. doi:10.1055/s-2002-23208. PMID 11928080.
  19. ↑ Iwase H, Maeda O, Shimada M, Tsuzuki T, Peek RM, Nishio Y, Ando T, Ina K, Kusugami K (2001). "Endoscopic ablation with cyanoacrylate glue for isolated gastric variceal bleeding". Gastrointest. Endosc. 53 (6): 585–92. PMID 11323583.

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