American College of Radiology
ACR Appropriateness Criteria®

Radiologic Management of Gastric Varices

Variant 1: Cirrhotic patient with active bleeding from large gastric varices exhibiting high flow by endoscopic Doppler ultrasound and a history of a wedge pressure of 20mmHg and a MELD score of 14. Three-phase contrast-enhanced CT demonstrates a large gastrorenal shunt.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
TIPS Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
BRTO Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Endoscopic management (sclerosis or cyanoacrylate injection) May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Cirrhotic patient with an index bleed from large gastric varices exhibiting high flow by endoscopic Doppler ultrasound with a MELD score of 20. Three-phase contrast-enhanced CT demonstrates a large gastrorenal shunt.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
TIPS May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
BRTO Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Endoscopic management (sclerosis or cyanoacrylate injection) May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Cirrhotic patient with small gastric variceal bleeding exhibiting slow flow by Doppler ultrasound and moderate ascites with a MELD score of 18. Contrast-enhanced MRI does not demonstrate a gastrorenal shunt.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
TIPS Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
BRTO May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Endoscopic management (sclerosis or cyanoacrylate injection) Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Cirrhotic patient with large gastric varices exhibiting high flow by endoscopic Doppler ultrasound and a significant history of hepatic encephalopathy with a MELD score of 18. Contrast-enhanced MRI demonstrates a large gastrorenal shunt.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
TIPS May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
BRTO Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Endoscopic management (sclerosis or cyanoacrylate injection) May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Cirrhotic patient with esophageal and gastric variceal bleeding (gastric varices considered high risk for endoscopic management/failed endoscopic management) with a MELD score of 13 and a history of hepatic wedge pressure of 22 mmHg. Three-phase contrast-enhanced CT demonstrates a small gastrorenal shunt.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
TIPS Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
BRTO May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Endoscopic management (sclerosis or cyanoacrylate injection) May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Cirrhotic patient with gastric variceal bleeding large gastric varices exhibiting high flow by endoscopic Doppler ultrasound with a MELD score of 12 and a history of a hepatic wedge pressure of 10 mmHg. Contrast-enhanced MRI demonstrates a large gastrorenal shunt.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
TIPS May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
BRTO Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Endoscopic management (sclerosis or cyanoacrylate injection) May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.