Gastrointestinal varices classification

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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	Varices visible during only one phase of respiration
	II	Varices visible during both phases of respiration
	III	3-6 mm in diameter
	IV	> 6 mm in diameter
Paquet’s classification	I	Microcapillaries located in : Distal esophagus Esophago-gastric junction
	II	1-2 variceal vessels located in the distal esophagus
	III	Medium-sized varices of any number
	IV	Large-sized varices in any part of esophagus
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	Extension of esophageal varices across the squamo-columnar junction
	2	Varices located in gastric fundus Overlap with esophageal varices in the esophagus at cardiac end
	3	Gastric varices in gastric fundus or body No esophageal varices
Mathur’s classification	1	Esophageal varices with 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 gastric fundus
	5	Varices in the gastric antrum
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 cardiac of the stomach Lf: Fundic areas of the stomach
	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	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 gastric fundus and cardia without esophageal varices
	Isolated gastric type 2	Varices outside of cardio-fundal region or first part of duodenum

References

↑ BUTLER H (1951). "The veins of the oesophagus". Thorax. 6 (3): 276–96. PMC 1018380. PMID 14884140.
↑ Sternlieb I, Scheinberg IH, Walshe JM (1970). "Bleeding oesophageal varices in patients with Wilson's disease". Lancet. 1 (7648): 638–41. PMID 4190630.
↑ 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.
↑ Dagradi AE, Stempien SJ, Owens LK (1966). "Bleeding esophagogastric varices. An endoscopic study of 50 cases". Arch Surg. 92 (6): 944–7. PMID 5295832.
↑ 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.
↑ "The general rules for recording endoscopic findings on esophageal varices". Jpn J Surg. 10 (1): 84–7. 1980. PMID 7373958.
↑ 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.
↑ 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.
↑ "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.
↑ "Reliability of endoscopy in the assessment of variceal features. The Italian Liver Cirrhosis Project". J. Hepatol. 4 (1): 93–8. 1987. PMID 3494762.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ Hosking SW, Johnson AG (1988). "Gastric varices: a proposed classification leading to management". Br J Surg. 75 (3): 195–6. PMID 3349325.
↑ Hashizume M, Kitano S, Yamaga H, Koyanagi N, Sugimachi K (1990). "Endoscopic classification of gastric varices". Gastrointest. Endosc. 36 (3): 276–80. PMID 2365213.
↑ 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.
↑ 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.
↑ 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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[pmid14884140-1] BUTLER H (1951). "The veins of the oesophagus". Thorax. 6 (3): 276–96. PMC 1018380. PMID 14884140.

[pmid4190630-2] Sternlieb I, Scheinberg IH, Walshe JM (1970). "Bleeding oesophageal varices in patients with Wilson's disease". Lancet. 1 (7648): 638–41. PMID 4190630.

[pmid14109008-3] 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.

[pmid5295832-4] Dagradi AE, Stempien SJ, Owens LK (1966). "Bleeding esophagogastric varices. An endoscopic study of 50 cases". Arch Surg. 92 (6): 944–7. PMID 5295832.

[pmid6066657-5] 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.

[pmid7373958-6] "The general rules for recording endoscopic findings on esophageal varices". Jpn J Surg. 10 (1): 84–7. 1980. PMID 7373958.

[pmid6975734-7] 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.

[pmid6352448-8] 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.

[pmid3262200-9] "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.

[pmid3494762-10] "Reliability of endoscopy in the assessment of variceal features. The Italian Liver Cirrhosis Project". J. Hepatol. 4 (1): 93–8. 1987. PMID 3494762.

[pmid2293575-11] 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.

[pmid26047908-12] 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.

[pmid8903373-13] 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.

[pmid2340395-14] 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.

[pmid3349325-15] Hosking SW, Johnson AG (1988). "Gastric varices: a proposed classification leading to management". Br J Surg. 75 (3): 195–6. PMID 3349325.

[pmid2365213-16] Hashizume M, Kitano S, Yamaga H, Koyanagi N, Sugimachi K (1990). "Endoscopic classification of gastric varices". Gastrointest. Endosc. 36 (3): 276–80. PMID 2365213.

[pmid1446890-17] 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.

[pmid11928080-18] 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.

[pmid11323583-19] 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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