variceal bleeding is the most common lethal complication of cirrhosis , with a mortality rate of 20% . gastroesophageal varices ( govs ) are present in 50% of cirrhotics , and approximately 25% of patients with portal hypertension have gastric varices . gastric varices are commonly classified as govs ( gastric varices in continuity with esophageal varices ) and isolated gastric varices ( igvs ) . these are further divided into gov1 ( govs along the lesser curve of the stomach ) , gov2 ( govs along the fundus ) , igv1 ( igvs in the fundus ) , and igv2 ( igvs in the gastric body , pylorus , or antrum ) . although the prevalence and risk of bleeding of gastric varices are lower than those of esophageal varices , gastric variceal bleeding tends to be more severe , requires more transfusions , and is associated with higher mortality ( ~45% ) . gastric varices tend to be larger and more tortuous compared with esophageal varices , characteristics that , combined with their anatomical location ( particularly fundic varices ) , make endoscopic management more challenging . current management strategies for gastric varices include pharmacotherapy ( -blockers and vasoactive agents ) , endoscopic therapy ( band ligation , thrombin , and tissue adhesives ) , transjugular intrahepatic portosystemic shunt ( tips ) placement , and surgical intervention . therefore , recommendations for management of gastric varices are based on recent prospective and retrospective studies , expert consensus opinion , and experience with esophageal varices . the pathophysiology of gastric varices is not as well understood as that of esophageal varices ; however , the former are mostly seen in patients with cirrhotic portal hypertension . no studies to evaluate pharmacologic therapy or endoscopic therapy for primary prophylaxis of gastric varices have been performed , and recommendations are based primarily on the guidelines for managing esophageal varices . large gastric varices with red color signs , especially in patients with advanced liver disease ( child 's class c ) , are most likely to bleed . endoscopic therapy and tips are both considered first - line treatments for gastric variceal bleeding ; however , current guidelines favor endoscopy as the preferred initial intervention . endoscopic therapeutic options for gastric variceal bleeding include band ligation , tissue adhesives , thrombin , and sclerotherapy . the greatest evidence exists for tissue adhesives such as cyanoacrylate ( n - butyl-2-cyanoacrylate , cyanoacrylate undergoes rapid polymerization on contact with living tissues and obliteration of varices occurs when the injected cyanoacrylate adhesive hardens on contact with blood . two randomized controlled trials have compared cyanoacrylate injection with variceal band ligation , showing mixed results for initial hemostasis but reduced rebleeding rates with cyanoacrylate ( 22% versus 44% and 31% versus 54% ) . another study compared cyanoacrylate injection with sclerotherapy and found better control of initial hemostasis as well as lower rebleeding rates with cyanoacrylate . meticulous adherence to technique is crucial when using tissue adhesives to prevent irreversible damage to endoscopes caused by polymerization . a recent study reported the use of endoscopic ultrasound to guide injection of feeding veins with excellent results ; however , the risk of damaging expensive equipment may prevent its widespread usage . complications of tissue adhesives include embolization , with case reports of portal vein embolization , coronary emboli , splenic infarction , pulmonary emboli , and cerebral stroke [ 13 - 16 ] . thrombin is a promising agent that does not carry the risk of embolization and damage to equipment . a recent study using bovine thrombin to control gastric variceal bleeding demonstrated a hemostasis rate of 92% and no episodes of rebleeding . several other studies with thrombin have shown promising results [ 17 - 19 ] . however , controlled trials comparing thrombin with other agents are required before it is universally accepted . the role of tips in the management of gastric varices alone or in comparison with esophageal varices has been investigated in multiple studies . chau et al .   reported a 96% initial hemostasis rate and 29% rebleeding rate with tips in patients with fundal varices , and these were similar to the rates for cirrhotics with esophageal varices . in another retrospective series comparing tips in 40 cirrhotics with gastric variceal bleeding and 232 patients with esophageal variceal bleeding , the rates of rebleeding were similar ( 20% versus 15% ) . clearly , with hemostasis rates over 90% , tissue adhesives and tips are both highly effective management options for gastric variceal bleeding . lo et al .   carried out a randomized controlled trial comparing tips ( n = 35 ) and cyanoacrylate glue ( n = 37 ) for secondary prophylaxis of gastric variceal bleeding . however , the rebleeding rate was significantly higher in the cyanoacrylate arm compared with the tips arm ( 38% versus 11% ) . in a uk - based retrospective study , the two therapies were equally effective for initial hemostasis but patients with tips had a lower rebleeding rate ( 20% versus 35% ) . however , tips was considerably more expensive than cyanoacrylate therapy . finally , in a recent retrospective study comparing tips ( n = 44 ) and cyanoacrylate therapy ( n = 61 ) for gastric variceal bleeding , rebleeding rates and mortality rates were similar between the two groups . however , the tips group had increased morbidity requiring hospitalization and had a higher incidence of encephalopathy ( 11 versus 1 ) . the pathophysiology of gastric varices is not as well understood as that of esophageal varices ; however , the former are mostly seen in patients with cirrhotic portal hypertension . no studies to evaluate pharmacologic therapy or endoscopic therapy for primary prophylaxis of gastric varices have been performed , and recommendations are based primarily on the guidelines for managing esophageal varices . large gastric varices with red color signs , especially in patients with advanced liver disease ( child 's class c ) , are most likely to bleed . endoscopic therapy and tips are both considered first - line treatments for gastric variceal bleeding ; however , current guidelines favor endoscopy as the preferred initial intervention . endoscopic therapeutic options for gastric variceal bleeding include band ligation , tissue adhesives , thrombin , and sclerotherapy . the greatest evidence exists for tissue adhesives such as cyanoacrylate ( n - butyl-2-cyanoacrylate , cyanoacrylate undergoes rapid polymerization on contact with living tissues and obliteration of varices occurs when the injected cyanoacrylate adhesive hardens on contact with blood . two randomized controlled trials have compared cyanoacrylate injection with variceal band ligation , showing mixed results for initial hemostasis but reduced rebleeding rates with cyanoacrylate ( 22% versus 44% and 31% versus 54% ) . another study compared cyanoacrylate injection with sclerotherapy and found better control of initial hemostasis as well as lower rebleeding rates with cyanoacrylate . meticulous adherence to technique is crucial when using tissue adhesives to prevent irreversible damage to endoscopes caused by polymerization . a recent study reported the use of endoscopic ultrasound to guide injection of feeding veins with excellent results ; however , the risk of damaging expensive equipment may prevent its widespread usage . complications of tissue adhesives include embolization , with case reports of portal vein embolization , coronary emboli , splenic infarction , pulmonary emboli , and cerebral stroke [ 13 - 16 ] . thrombin is a promising agent that does not carry the risk of embolization and damage to equipment . a recent study using bovine thrombin to control gastric variceal bleeding demonstrated a hemostasis rate of 92% and no episodes of rebleeding . several other studies with thrombin have shown promising results [ 17 - 19 ] . however , controlled trials comparing thrombin with other agents are required before it is universally accepted . the role of tips in the management of gastric varices alone or in comparison with esophageal varices has been investigated in multiple studies . chau et al .   reported a 96% initial hemostasis rate and 29% rebleeding rate with tips in patients with fundal varices , and these were similar to the rates for cirrhotics with esophageal varices . in another retrospective series comparing tips in 40 cirrhotics with gastric variceal bleeding and 232 patients with esophageal variceal bleeding , the rates of rebleeding were similar ( 20% versus 15% ) . clearly , with hemostasis rates over 90% , tissue adhesives and tips are both highly effective management options for gastric variceal bleeding . .   carried out a randomized controlled trial comparing tips ( n = 35 ) and cyanoacrylate glue ( n = 37 ) for secondary prophylaxis of gastric variceal bleeding . however , the rebleeding rate was significantly higher in the cyanoacrylate arm compared with the tips arm ( 38% versus 11% ) . in a uk - based retrospective study , the two therapies were equally effective for initial hemostasis but patients with tips had a lower rebleeding rate ( 20% versus 35% ) . however , tips was considerably more expensive than cyanoacrylate therapy . finally , in a recent retrospective study comparing tips ( n = 44 ) and cyanoacrylate therapy ( n = 61 ) for gastric variceal bleeding , rebleeding rates and mortality rates were similar between the two groups . however , the tips group had increased morbidity requiring hospitalization and had a higher incidence of encephalopathy ( 11 versus 1 ) . the initial steps in the management of gastric variceal bleeding are similar to esophageal varices and include attention to airway and obtaining intravenous access with prompt hemodynamic resuscitation , institution of vasoactive medications ( somatostatin analogues , octreotide , vasopressin , and terlipressin ) to reduce portal pressure by splanchnic vasoconstriction and prophylactic antibiotics followed by diagnostic and potentially therapeutic upper endoscopy ( figure 1 ) . the next step in the management may be endoscopic injection of tissue adhesives or tips placement . with a lower complication rate , comparable hemostasis and survival rates , and lower cost , endoscopic therapy with tissue adhesives is likely to be the treatment of choice for acute bleeding and secondary prophylaxis in most patients . on the other hand , tips will remain an important second - line modality in patients who fail endoscopic therapy . however , additional controlled studies are needed before valid conclusions can be made , and individual patient characteristics must be considered in management decisions . primary prophylaxis may be instituted with -blockers in patients with large varices with red color signs and advanced liver disease . further research on management of acute bleeding , primary prophylaxis , and comparisons between tissue adhesives and thrombin would be welcome .