Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

Table 9 Differences between portal hypertensive gastropathy and gastric antral vascular ectasia

Parameter	Portal hypertensive gastropathy	Gastric antral vascular ectasia	Ref.
Associated conditions	Conditions associated with portal hypertension: cirrhotic or non-cirrhotic portal hypertension	Cirrhosis, autoimmune disorders, and connective tissue diseases (scleroderma, pernicious anemia, hypothyroidism)	[72]
Association with portal hypertension	Strong association	Only 30% of cases	[191,192]
Sex	Mildly more common in males (alcoholic cirrhosis more common in males than females)	Much more common in females (80%)	[193,194]
Age	Can occur at any age in patients with portal hypertension or cirrhosis	Typically elderly (average age > 70 years old)
Location	Proximal stomach: Fundus, body	Distal stomach: Antrum	[72,192]
Diagnosis	Endoscopy (endoscopic biopsy sometimes useful). Radiologic imaging usually not helpful	Endoscopy (endoscopic biopsy sometimes useful)	[72,195]
Appearance at endoscopy	Mosaic/snakeskin mucosa with red or brown spots	Tortuous columns of ectatic vessels in "watermelon" or diffuse pattern; erythematous or hemorrhagic	[191]
Histology	Ectatic capillaries, mildly dilated mucosal and submucosal veins; no vascular inflammation, no vascular thrombi	Marked dilation of capillaries and venules in gastric mucosa and submucosa with areas of intimal thickening, fibrin thrombi, fibromuscular hyperplasia and spindle cell proliferation	[72,191,196,197]
Clinical presentation/ complications	Gastrointestinal bleeding: Usually chronic, but sometimes acute	Almost exclusively chronic gastrointestinal bleeding with guaiac positive stools	[37,193]
Primary prophylaxis	Not indicated	Not indicated (unless associated with large varices)	[198]
Medical therapy	Non-selective β-adrenergic receptor antagonists (propranolol), octreotide (for acute bleeding)	No benefit of β-adrenergic receptor antagonists	[103,106,198-201]
		Oral contraceptive pills to temporarily control bleeding
		Questionable benefit of octreotide
Endoscopic therapy	Occasionally helpful (for focal bleeding)	Very helpful at reducing risk of bleeding: Argon plasma coagulation; EBL; Radiofrequency ablation; YAG laser therapy	[202-207]
	Argon plasma coagulation
	Local hemostasis with hemospray
TIPS	Significantly reduces severity and risk of bleeding by reducing portal hypertension. Option for very severe bleeding from PHG or for moderate PHG in patients with variceal bleeding	Not recommended. Does not affect severity of GAVE or risk of bleeding	[75,77]
Liver transplantation	Resolves. Ultimate therapy mostly reserved for patients with end-stage liver disease	Improves or resolves with liver transplantation	[75,200,208-210]
Other surgery	Usually resolves with shunt surgery that lowers portal pressure. Partial gastrectomy not recommended	Limited surgical resection (partial gastrectomy) recommended for refractory cases. Shunt surgery not recommended	[75,200,211-213]
Prognosis from bleeding	Bleeding rarely severe and very rarely fatal	Bleeding occasionally severe	[34,71,72]

YAG: Yttrium aluminum garnet; TIPS: Transjugular intrahepatic portosystemic shunt; PHG: Portal hypertensive gastropathy; GAVE: Gastric antral vascular ectasia; EBL: Endoscopic band ligation.