C. Worsening portal hypertension, ascites, and other variceal bleeding

Transvenous obliteration (TO) is successful in eradicating gastric varices in 88-100% of cases with gastric variceal rebleeding in 0-7% over the next 24 months. Gastric varices tend to bleed at lower portal pressures than esophageal varices, so variceal embolization or TO is classically thought to be more effective for gastric varices than TIPS alone. The downside of TO alone is worsening portal hypertension leading to issues with ascites or other variceal bleeding. As such, the majority of patients who receive a TO ultimately need a TIPS within 3 years.

For completeness, endoscopic banding often fails due to the acidity of gastric juices. Endoscopic cyanoacrylate injection can be effective with variceal eradication in 95% and rebleeding in 19%.

Which of the following patients would be a good candidate for TIPS as well as transvenous obliteration or variceal embolization?

A. 65 yo EtOH cirrhosis, MELD 11, Child Pugh C

B. 51 yo NASH cirrhosis, MELD 25, Child Pugh C

C. 67 yo NASH cirrhosis, MELD 9, Child Pugh B with endoscopic evidence of variceal bleeding

D. 49 yo cryoptogenic cirrhosis, MELD 10, Child Pugh A with non-bleeding varices

E. A and C

F. A and B

G. All of the above