Copyright
©The Author(s) 2016.
World J Hepatol. Feb 8, 2016; 8(4): 231-262
Published online Feb 8, 2016. doi: 10.4254/wjh.v8.i4.231
Published online Feb 8, 2016. doi: 10.4254/wjh.v8.i4.231
Table 1 Rates of portal hypertensive gastropathy in patients with portal hypertension
Ref. | Analyzed patients | Total number | No. (%) with PHG | No. (%) with mild PHG | No. (%) with severe PHG |
McCormack et al[3] | Portal hypertension | 127 | 65 (51%) | 37 (29%) | 28 (22%) |
Sarin et al[5] | Portal hypertension | 136 | 10 (7%) | ||
DeWeert et al[6] | Non-alcoholic liver disease | 81 | 23 (28%) | Not reported | Not reported |
McCormick et al[7] | Portal hypertension | 93 endoscopies in 74 patients | 85 endoscopies (91%) | 6 (6%), moderate 61 (66%) | 18 (19%) |
Sarin et al[8] | Portal hypertension | 107 | 4 (3.7%) (only cirrhotic) | Not reported | Not reported |
Parikh et al[9] | Portal hypertension | 118 | 71 (60%) | 41 (58%) | 30 (42%) |
Sarin et al[10] | Portal hypertension with prior variceal bleeding | 967 | 86 (9%) | 56 (5.8%) | 30 (3.1%) |
Itha et al[11] | EHPVO in children | 163 | (12%) | Not reported | Not reported |
Rana et al[12] | Portal hypertension | 41 | 27 (66%) | 19 (46%) | 8 (20%) |
El-Rifai et al[13] | Portal hypertension | 24 | 14 (58%) | 10 (42%) - moderate | 4 (16%) |
Sogaard et al[14] | Portal vein thrombosis | 67 | 28 (42%) | Not reported | Not reported |
Figueiredo et al[15] | Portal hypertension; cirrhosis | 36 | 27 (75%) | 5 (46%) | |
Erden et al[16] | Portal hypertension | 57 | 15 (26.3%) | Not reported | Not reported |
Duché et al[17] | Children, portal hypertension with biliary atresia | 125 | 27 (21%) | Not reported | Not reported |
Aydoğan et al[18] | Portal hypertension | 51 | 30 (58%) | Not reported | Not reported |
dos Santos et al[19] | Portal hypertension | 43 | 22 (51%) | Not reported | Not reported |
Pantham et al[20] | Esophageal varices undergoing TEE | 24 | 12 (50%) | Not reported | Not reported |
Abdollahi et al[21] | Autoimmune hepatitis | 60 | 27 (45%) | Not reported | Not reported |
de Alcantara et al[22] | Chronic liver disease vs EHPVO | 35 vs 18 | 7 (20%) vs 8 (44.4%) | Not reported | Not reported |
Aoyama et al[23] | Portal hypertension | 119 | 35 (29%) | Not reported | Not reported |
Table 2 Rates of portal hypertensive gastropathy in patients with cirrhosis
Ref. | Patients | Total number | PHG | Mild | Severe |
Sacchetti et al[24] | Cirrhosis | 142 | 38 (27%) | 28 (20%) | 10 (7%) |
D'Amico et al[25] | Cirrhosis | 212 | 130 (61%) | 110 (52%) | 20 (9%) |
Calès et al[26] | Cirrhosis | 100 | 98 (98%) | 57 (57%) | 41 (41%) |
Rabinovitz et al[27] | Cirrhosis | 510 | (43%) | Not reported | Not reported |
Iwao et al[28] | Cirrhosis | 47 | 32 (68%) | 15 (32%) | 17 (36%) |
Taranto et al[29] | Cirrhosis | 394 | 317 (80.5%) | Not reported | Not reported |
Gupta et al[30] | Cirrhosis | 230 | (61%) | (52%) | (9%) |
Iwao et al[31] | Cirrhosis | 476 | 254 (53%) | 208 (43%) | 46 (9%) |
Carpinelli et al[32] | Cirrhosis | 566 | 362 (64%) | 192 (34%) | 170 (30%) |
Zaman et al[33] | Cirrhosis | 120 | 74 (62%) | 47 (39%) | 27 (23%) |
Primignani et al[34] | Cirrhosis | 373 | 299 (80%) | 127 (34%) | 172 (46%) |
Chaves et al[35] | Cirrhosis vs schistosomiasis | 43 | 18 (81%) vs 7 (33%) | Not reported | Not reported |
Merkel et al[36] | Cirrhosis | 62 | 49 (79%) | 29 (46%) | 20 (32%) |
Merli et al[37] | Cirrhosis, with mild portal hypertension | 222 | 48 (21%) | 43 (19%) | 5 (2%) |
Ito et al[38] | Cirrhosis | 47 | 13 (27%) | 10 (21%) | 3 (6%) |
De Palma et al[39] | Cirrhosis | 37 | 23 (62%) | Not reported | Not reported |
Menchén et al[40] | Cirrhosis | 549 | 353 (64%) | 275 (50%) | 77 (14%) |
Yüksel et al[41] | Cirrhosis | 114 total | 76 (66%) | 38 (33%) | 38 (33%) |
Fontana et al[42] | Cirrhosis or bridging fibrosis from hepatitis C | 1016 | 374 (37%) | 345 (34%) | 29 (3%) |
Bresci et al[43] | Cirrhosis | 85 | 36 (42%) | Not reported | Not reported |
Akatsu et al[44] | End stage liver disease | 29 | 19 (65.5%) | 18 (62.1%) | 1 (3.4%) |
Zardi et al[45] | Cirrhosis | 266 | 84 (31%) | Not reported | Not reported |
Barakat et al[46] | Cirrhosis with portal hypertensive duodenopathy | 105 | 105 (100%) | 17 (16.2%) | 88 (83.8%) |
Bellis et al[47] | Cirrhosis | 59 | 44 (76%) | 16 (27%) | 28 (47%) |
Gravante et al[48] | Liver transplant candidates with cirrhosis | 80 | 41 (51.2%) | Not reported | Not reported |
Canlas et al[49] | Cirrhosis | 19 | 13 (68.4%) | Not reported | Not reported |
Kim et al[50] | Cirrhosis | 83 | 48 (57.8%) | Not reported | Not reported |
Higaki et al[51] | Cirrhosis | 21 | 8 (38%) | Not reported | Not reported |
Frenette et al[52] | Cirrhosis | 50 | 45 (90%) | 28 (56%) | 17 (34%) moderate |
Tarantino et al[53] | Cirrhosis | 153 | 88 (57.5%) | Not reported | Not reported |
Curvêlo et al[54] | Cirrhosis | 46 | 43 (93.4%) | 21 (45%) | 22 (47%) |
Anegawa et al[55] | Cirrhosis | 70 | 49 (70%) | 32 (46%) | 17 (24%) |
Kumar et al[56] | Cirrhosis | 254 | 140 (55%) | Not reported | Not reported |
Kim et al[57] | Cirrhosis | 331 | 298 (90%) | Mild 84 (25.4%) | 214 (64.7%) |
De Lisi et al[58] | Cirrhosis | 611 | 448 (73.3%) | 37.3% | 36% |
Abbasi et al[59] | Cirrhosis | 102 | 87 (85%) | Not reported | Not reported |
Ahmed et al[60] | Cirrhosis from hepatitis B or hepatitis C | 360 | 300 (83%) | 229 (64%) | 71 (20%) |
Garcia-Saenz-de-Sicilia et al[61] | Cirrhosis | 105 | 72 (68.6%) | Not reported | Not reported |
Abbasi et al[62] | Cirrhosis | 217 | 172 (79.3%) | 56 (25.8%) | 116 (53.5%) |
Aoyama et al[63] | Cirrhosis | 60 | 13 (22%) | Not reported | Not reported |
Laleman et al[64] | Cirrhosis with refractory chronic hepatic encephalopathy | 36 | 13 (36%) | 9 (25%) | 4 (11%) |
Giannini et al[65] | Cirrhosis and undergoing surgery for hepatocellular carcinoma | 152 | 23 (15.1%) | Not reported | Not reported |
Abdollahi et al[21] | Autoimmune hepatitis | 60 | 27 (45%) | Not reported | Not reported |
Aoyama et al[23] | Portal hypertension | 119 | 35 (29%) | Not reported | Not reported |
Aoyama et al[66] | Cirrhosis | 134 | 42 (31%) | Not reported | Not reported |
Zardi et al[67] | Cirrhosis without gastroesophageal varices | 145 | 75 (51%) | 45 (31%) | 30 (20%) |
Wu et al[68] | Cirrhosis | 700 | 449 (64%) | Mild 208 (29.7), moderate 160 (22.9%) | Severe 81 (11.6%) |
Table 3 Effects of variceal ligation on frequency of portal hypertensive gastropathy
Ref. | No. of patients and etiology | Study type | PHG rate before variceal ligation | PHG aggravation after variceal ligation | P value of pre vs post EVL |
Hou et al[73] | 90 patients with cirrhosis and recent variceal bleeding, 46 patients underwent EVL | Randomized, controlled trial | No PHG-4, mild PHG-33, severe-PHG-9 | At eradication: 17/37; 17/37 (45.9%) in EVL; at 3 mo: 17/30 (56.7%); at 6 mo 18/29 (62.1%) | P > 0.05 |
Elnaser et al[80] | 125 patients with upper GI bleeding undergoing variceal ligation, followed for mean of 31 mo | Retrospective study | 22/125 (17.6%) | 50/125 (50%) | P < 0.05 |
Yüksel et al[41] | 114 patients with cirrhosis and portal hypertension undergoing EVL in 85 patients | Retrospective study | 27/85 (31.8%) none; 28/85 (32.9%) mild; 30/85 (35.3%) severe | 14/85 (16.5%) none; 30/85 (35.3%) mild; 41/85 (48.2%) severe | P < 0.05 |
Lo et al[81] | 77 patients with bleeding from EV underwent variceal ligation and were randomized to receive propranolol (37/77) or control (40/77); patients with severe PHG prior to treatment excluded from the study | Prospective, randomized, controlled trial | Control group: 7/40 (17%); propranolol group: 8/37 (22%) | At variceal ligation: Control group: 67% (does not state number); Propranolol group: 31% (number not stated); 6 mo after treatment: Control group: 85% (number not stated) propranolol group: 48% (number not stated) | Pre vs post ligation, both groups; P < 0.05; frequency of PHG significantly higher in control group post ligation when compared to propranolol group; P = 0.002 |
de la Peña et al[82] | 93 patients with history of variceal hemorrhage and cirrhosis, randomized to receive either EVS (46/88) or EVL (42/88); 5 patients excluded due to diagnosis of hepatoma, non-cirrhotic portal hypertension or portal vein thrombosis | Randomized, prospective study | Not reported | PHG significantly worsened in 23 patients, including 17 patients undergoing EVL | P < 0.01 |
Table 4 Effects of variceal sclerotherapy on frequency of portal hypertensive gastropathy
Ref. | No. of patients and etiology | Study type | PHG before procedure | PHG aggravation after procedure | P value |
Hou et al[73] | 90 cirrhotic patients with recent variceal bleeding; EVS 44, EVL 46 | Randomized, controlled trial | Pre EVS group: 6 none/24 mild/14 severe; pre EVL group: 4 none/33 mild/9 severe; total: 10 none/57 mild/23 severe | At eradication: 14/29 (48.3%) in EVS; 17/37 (45.9%) in EVL; at 3 mo: 15/26 (57.7%) in EVS; 17/30 (56.7%) in EVL; at 6 mo 15/25 (60%) in EVS; 18/29 (62.1%) in EVL | Non-significant difference in PHG aggravation between EVS and EVL; P > 0.05 |
Itha et al[11] | 163 children with extrahepatic portal vein obstruction presenting with variceal bleeding underwent endoscopic injection sclerotherapy | Not reported | 12% overall PHG (actual number not stated), 1 patient with severe PHG | 41% overall PHG (actual number not stated), 12 patients with severe PHG | P < 0.001 for overall PHG; P < 0.001 for severe PHG |
Poddar et al[83] | 186 children with extrahepatic portal vein obstruction presenting with variceal bleeding undergoing endoscopic sclerotherapy, and mean follow up of 38 ± 30 mo | Retrospective study | PHG: 46/186 (24.7%), severe PHG: 6/186 (3.2%) | PHG: 96/186 (51.6%), severe PHG: 29/186 (15.6%) | P < 0.001 for overall PHG; P < 0.05 for severe PHG |
Yüksel et al[41] | 114 patients with cirrhosis and portal hypertension undergoing EVS (29/114) or EVL (85/114) | Retrospective study | Pre EVS group: 11/29 (37.9%) none; 10/29 (24.5%) mild; 8/29 (27.6%) severe; pre EVL group: 27/85 (31.8%) none; 28/85 (32.9%) mild; 30/85 (35.3%) severe | Post EVS group: 4/29 (13.8%) none; 8/29 (27.6%) mild; 17/29 (58.6%) severe; post EVL group: 14/85 (16.5%) none; 30/85 (35.3%) mild; 41/85 (48.2%) severe | Pre EVS vs post EVS; P < 0.05; pre EVL vs post EVL; P < 0.05; pre EVS vs pre EVL; P > 0.05; post EVS vs post EVL; P > 0.05 |
Sarin et al[10] | 967 patients with variceal bleeding underwent endoscopic sclerotherapy; out of whom 88 patients fulfilled the inclusion criteria (including presence of endoscopic lesions consistent with PHG or GAVE, before or within 4 wk after obliteration) were prospectively followed (out of whom 2 had only GAVE) | Prospective study | 22 patients had PHG prior to EVS; 2/22 transient (9%); 17/22 persistent (77%); 3/22 progressive (14%) | Additional development in 64 patients post procedure, 28/64 transient (44%), 31/64 persistent (48%), 5/64 progressive (8%) | Only statistically significant difference was the transient PHG that disappeared in 28 (44%) of patients in the group that developed PHG post procedure; P < 0.05 |
Gupta et al[30] | 230 patients with liver cirrhosis; of which 44 underwent variceal eradication with sclerotherapy | Prospective study | 24/44 (54%) | 33/44 (75%) | P < 0.05 |
Sarin et al[8] | 107 patients with portal hypertension presenting with variceal bleeding that underwent sclerotherapy with mean follow-up of 23.2 ± 3.4 mo | Prospective study | 4/107 (3.7%) | 21 additional patients, 25/107 (23%) | Does not state if this was statistically significant |
de la Peña et al[82] | 93 patients with history of variceal hemorrhage and cirrhosis, randomized to receive either EVS (46/88) or EVL (42/88); 5 patients were excluded due to diagnosis of hematoma, non-cirrhotic portal hypertension or portal vein thrombosis | Prospective study | Not reported | PHG worsened in 23 patients total; statistically significantly more in EVL group than EVS group (17 vs 6 patients respectively) | P < 0.01 |
D'Amico et al[25] | 212 cirrhotic patients of which 75 had an episode of variceal bleeding and were treated with sclerotherapy; 137 without bleeding were not treated with sclerotherapy | Prospective study | No EVS group at admission: 104/137 (75%) none; 28/137 (20%) mild; 5/137 (4%) severe; EVS group at admission: 50/75 (66%) none; 17/75 (22%) mild; 8/75 (11%) severe | No EVS group at end of study 69/137 (50%) none; 61/137 (45%) mild; 7/137 (5%) severe; EVS group at end of study: 13/75 (17%) none; 49/75 (65%) mild; 13/75 (17%) severe | The conclusion was that sclerotherapy is a significant indicator of the risk of PHG in a multivariate analysis (P = 0.00032) |
Table 5 Well-established, important risk factors for portal hypertensive gastropathy
Parameters | Ref. |
Portal hypertension | |
Non-cirrhotic portal hypertension | [8,14] |
Cirrhotic portal hypertension | [8,9,34] |
Cirrhosis | |
Longer duration of cirrhosis | [34,71] |
Greater severity of cirrhosis | [55,67] |
Greater size of esophageal varices | [34,62] |
Eradication of esophageal varices | |
Endoscopic therapies | |
Endoscopic variceal ligation | [11,41] |
Endoscopic sclerotherapy | [11,83] |
Angiographic | |
Percutaneous transhepatic variceal embolization | [85] |
Table 6 Therapies affecting the severity or the risk of bleeding from portal hypertensive gastropathy
Therapies reducing severity of PHG | Ref. |
TIPS | [76,77,98] |
Transcatheter splenic arterial embolization | [99] |
Surgical shunt | |
Portocaval shunt | [100] |
Central splenorenal shunt | [101] |
Laparoscopic splenectomy (in patients with hypersplenism) | [55] |
Liver transplantation | [44] |
Therapies reducing risk of bleeding from PHG | |
TIPS | [75,98,102] |
Surgical shunt (portocaval or splenorenal) | [100,101] |
Nonselective b β-adrenergic receptor antagonists (e.g., propranolol) | [103 (in rats),104] |
Somatostatin family of drugs | |
Somatostatin | [105] |
Octreotide | [106] |
Vasopressin family of drugs | |
Vasopressin | [106] |
Terlipressin | [107] |
Therapies that increase incidence or risk of bleeding from PHG | |
Endoscopic therapies for varices | |
Variceal ligation | [11,41] |
Variceal sclerotherapy | [11,83] |
Interventional angiography | |
Percutaneous transhepatic variceal embolization | [85] |
Table 7 Factors not affecting risk of portal hypertensive gastropathy
Factors not affecting risk of portal hypertensive gastropathy | Ref. |
Etiology of cirrhosis | [8,28,30] |
Etiology of non-cirrhotic portal hypertension | [8,14,35,83,108] |
Alcoholism | [30,42] |
NSAID use | [42] |
Use of COX-2 inhibitors | [42] |
Smoking tobacco | [42] |
Gastric infection with Helicobacter pylori | [109,110] |
Table 8 Different classification systems for portal hypertensive gastropathy
Ref. | Mild | Moderate | Severe |
McCormack et al[3] | Fine pink speckling (scarlatina type rash) | Discrete red spots (analogous to cherry | |
Superficial reddening, especially on rugal surface (striped appearance) | red spots in esophagus) | ||
Fine white reticular pattern separating areas of raised edematous mucosa (snake skin) | Diffuse hemorrhagic gastritis | ||
McCormick et al[7] | Mosaic or snake skin appearance | Presence of erythema | Presence of erosions or hemorrhagic gastritis |
Tanoue et al[180] | Mild reddening, congestive mucosa, no mosaic - like pattern | Severe redness and a fine reticular pattern separating the areas of raised edematous mucosa (mosaic-like pattern) or a fine speckling | Grade III (severe) |
Point bleeding + grade II (moderate) | |||
Spina et al[70] (NIEC) | Mosaic-pattern: Presence of small, | Red point lesions (1 mm in diameter, flat) | |
polygonal areas surrounded by a | Cherry-red spots (2 mm, slight protrusion) | ||
whitish-yellow depressed border | Black-brown spots (irregularly shaped, persistently present after washing) | ||
Sarin et al[8] | Discrete cherry red spots, with or without mosaic pattern | Presence of confluent red spots, diffusely distributed in a large portion of the stomach | |
Sarin et al[181] (Baveno II Consensus Workshop)[181] | Mild ≤ 3 points1 | Severe ≥ 4 points1 | |
Gastric antral ectasia | |||
Absent (0) | |||
Present (2) | |||
Yoo et al[182] | Fine pink speckling (scarlatina type rash) | Discrete red spots | |
2-category classification | Superficial reddening | Diffuse hemorrhagic lesion | |
Mosaic pattern | |||
Yoo et al[182] | Mild reddening | Flat red spot in center of a pink areola | Diffusely red areola |
3-category classification | Congestive mucosa | Severe redness and a fine reticular pattern | Pinpoint bleeding |
Diffuse pink areola | Discrete or confluent red mark lesion |
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] |
Table 10 Differences in gastrointestinal bleeding from portal hypertensive gastropathy vs esophageal varices
Parameter | Portal hypertensive gastropathy | Esophageal varices |
Etiology | Portal hypertension: Cirrhotic or non-cirrhotic | Portal hypertension: Cirrhotic or non-cirrhotic |
Concurrence | Frequently occur simultaneously with esophageal varices because the two diseases share common risk factors | Frequently occurs simultaneously with PHG because the two diseases have common risk factors |
Location | Stomach: Predominantly fundus and body | Distal esophagus: Also can have gastric varices or ectopic varices in other gastrointestinal regions, particularly duodenum |
Diagnosis | Esophagogastroduodenoscopy | Esophagogastroduodenoscopy |
Endoscopic appearance | Erythematous small polygonal areas of mucosa surrounded by a fine, whitish, reticular or mosaic/snakeskin mucosa with red or brown spots | Serpiginous mucosal greyish luminal projections in distal esophagus |
Clinical presentation | Mild acute or chronic bleeding | Acute gastrointestinal bleeding-typically massive |
Severity of bleeding | Typically mild and not life-threatening | Typically severe and life-threatening |
Histology | Not biopsied at endoscopy | |
Endoscopic therapy | Limited role | Variceal ligation recommended as initial therapy. Sclerotherapy an alternative therapy |
Medical therapy | Octreotide | Octreotide |
Propranolol | Propranolol | |
Vasopressin or vasopressin analogues-infrequently recommended any more | Vasopressin or vasopressin analogues-infrequently recommended any more | |
Blakemore tube | Not recommended | Sometimes used for refractory bleeding especially as a temporizing measure before performing more definitive therapy |
Angiographic therapy | TIPS used as a last resort | TIPS recommended if endoscopic therapy fails |
Transfusion of packed erythrocytes | Transfuse only to hematocrit of about 28. Over-transfusion may increase portal pressure and induce greater bleeding | Transfuse only to hematocrit of about 28. Over-transfusion may increase portal pressure and induce greater bleeding |
Liver transplantation | Improves or resolves with liver transplantation | Improves or resolves with liver transplantation |
Prognosis | Rarely fatal | Frequently fatal |
Table 11 Rates of gastrointestinal bleeding from portal hypertensive gastropathy
Ref. | Year published | Population | Bleeding from PHG | Transfusions required |
McCormack et al[3] | 1985 | 127 patients with portal hypertension of various etiologies | 29 patients out of 65 with PHG, representing 25% of the total number of bleeds from all sources; 9 episodes presenting with bleeding; 71 episodes of subsequent bleeding | 2-15 units required for 60 bleeds |
D'Amico et al[25] | 1990 | 212 patients with cirrhosis; 75 being treated with sclerotherapy | ||
Sarin et al[8] | 1992 | 107 patients with portal hypertension presenting with variceal bleeding, undergoing sclerotherapy | No bleeding before sclerotherapy from PHG (4/107 had PHG); 2/13 post-sclerotherapy patients who developed PHG | Average of 4 units per patient with range of 2-8 units |
Pérez-Ayuso et al[103] | 1991 | 54 cirrhotic patients with PHG, in a RCT to look for rebleeding; propranolol 26 vs control 28 | First hemorrhage: Acute/chronic bleeding in propranolol group 12/14; in control 12/16, rebleeding: Acute/chronic; in propranolol 6/6; in control 10/12 | |
Gostout et al[217] | 1993 | Patients admitted for GI bleeding (1496) | 12 patients (0.8%), representing 8% of nonvariceal bleeding in patients with liver disease | |
Primignani et al[34] | 2000 | 373 patients with cirrhosis; PHG in 299 patients (80.1%) | 8 PHG patients with acute bleeding; chronic bleeding in 34 patients | |
Merli et al[37] | 2004 | 222 cirrhotic patients with portal hypertension; 48 patients with PHG on enrollment | During follow up for 47 ± 28 (SD) mo, acute bleeding 9, chronic bleeding 7 from PHG | |
Kimura et al[218] | 2014 | 297 patients with living donor liver transplantation; retrospective analysis | 2 patients bled from PHG within 3 mo after transplantation |
Table 12 Treatment of acute or chronic gastrointestinal bleeding from portal hypertensive gastropathy
Acute bleeding |
Patient stabilization |
Treat severe coagulopathy with highly elevated INR associated with cirrhosis with fresh frozen plasma |
Treat severe thrombocytopenia associated with hypersplenism and bone marrow suppression from alcoholism with platelet transfusions |
Transfuse packed erythrocytes to main hemoglobin level at about 8 g/dL |
Consider antibiotic prophylaxis in patient with cirrhosis |
Endoscopic therapy from bleeding-rarely used |
Consider argon plasma coagulation |
Hemospray - an experimental therapy |
Pharmacotherapy |
Octreotide - first line therapy |
Vasopressin or terlipressin - second line therapy |
Proton pump inhibitor therapy - adjunct therapy |
Propranolol - can be instituted after bleeding controlled and patient stabilized |
Interventional therapy |
TIPS - for uncontrolled hemorrhage or for bleeding from PHG associated with variceal bleeding |
Liver transplantation - for advanced end stage liver disease |
Chronic bleeding |
Treatment of anemia |
Transfusions of packed erythrocytes as necessary |
Iron replacement therapy |
Pharmacotherapy |
Consider propranolol |
- Citation: Gjeorgjievski M, Cappell MS. Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy. World J Hepatol 2016; 8(4): 231-262
- URL: https://www.wjgnet.com/1948-5182/full/v8/i4/231.htm
- DOI: https://dx.doi.org/10.4254/wjh.v8.i4.231