Management of gastric varices: treatment options and opportunities to improve outcomes

INTRODUCTION: Gastric varices represent a challenging clinical scenario due to the severity of consequences when bleeding occurs, the cohort of patients in which it occurs and a paucity of high-quality prospective data to guide treatment decisions. Whilst a range of endoscopic and radiologic management strategies are now available, ambiguity exists about when to utilize each of these therapies. AREAS COVERED: This study comprehensively reviewed current management considerations and the positioning of available treatment modalities for gastric varices. A literature search was performed using PubMed to identify peer-reviewed articles published until December 2025. EXPERT OPINION: Whilst a lack of large, randomized trials limits the ability to provide definitive guidance for the management of gastric varices, individualized patient care and a multidisciplinary approach with close collaboration between hepatologists, interventional endoscopists and radiologists is vital. Prompt endoscopic assessment remains important and allows initial management with either direct endoscopic injection (cyanoacrylate glue or thrombin) or if available, EUS-guided therapy. Further follow up endoscopic or EUS-guided therapies appear to be safe and effective, but definitive management with radiologic procedures such as transjugular intrahepatic portosystemic shunt to address global portal hypertension or retrograde transvenous obliteration procedures are highly successful and should also be considered.