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
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.