Gastric varices (GV) present a challenge not always amenable to conventional approaches applied to esophageal varices (EV). Several types of GV classification systems exist including the familiar Sarin system and lesser-known vascular classifications which provide a foundation for management triage. While GV bleeding is less frequent than EV bleeding, it is often more pronounced. Initial management follows that for EV including very cautious volume replacement and early use of vasoactive medications. Urgent temporizing measures, if needed, may include balloon tamponade, sclerosants, banding, clipping and possibly procoagulants. Imaging is important in early management as optimal modalities such as balloon retrograde transvenous obliteration (BRTO), transhepatic porto-systemic shunts (TIPS), cyanoacrylate or combination modalities are contingent on the underlying vascular anatomy. Each of these is associated with particular advantages and disadvantages as discussed below.