What is Portal Hypertensive Gastropathy (PHG)?
Portal Hypertensive Gastropathy, as the name indicates, is a condition which occurs as result of portal hypertension and comprises of changes in the stomach mucosa in people who are suffering from portal hypertension. Cirrhosis of the liver is the most common cause of portal hypertension. The changes in the stomach mucosa consist of presence of blood vessels ectasia at the surface and friability of the mucosa. Other symptoms experienced by the patients suffering from portal hypertensive gastropathy include bleeding from the stomach, which in rare cases can reveal itself by vomiting blood or by appearance of tarry stools/blood in stool (melena). Portal hypertension can also cause gastric varices and esophageal varices, which are other common causes of upper gastrointestinal bleeding. Upon endoscopic evaluation, the mucosa of the stomach displays a characteristic "snake-skin" or mosaic appearance.
Treatment of Portal Hypertensive Gastropathy consists of medications and procedural treatment.
Signs & Symptoms of Portal Hypertensive Gastropathy
Upon endoscopic evaluation, majority of the patients suffering from portal hypertensive gastropathy will exhibit an improving course or a stable course in the gastropathy appearance. Most of the patients suffering from portal hypertensive gastropathy will be asymptomatic. However, studies reveal that about 1 in 7 patients having portal hypertensive gastropathy will have either acute or chronic symptoms of bleeding from gastropathy.
A substantial number of patients will have symptoms which are associated with chronic gastrointestinal bleeding and chronic iron deficiency/blood loss anemia and a small number of patients will have symptoms of active GI bleeding. Patients having chronic bleeding will suffer from anemia, which makes them seek medical attention. Chronic bleeding symptoms of portal hypertensive gastropathy is a term used to describe a condition where there is decrease of hemoglobin about 2 g/dL within six-month duration without the use of nonsteroidal anti-inflammatory drugs and without any symptoms of acute bleeding. Symptoms of chronic bleeding may also cause iron deficiency anemia and patient can have a positive fecal occult blood test.
Acute GI bleeding is less common. Diagnosis of acute bleeding due to portal hypertensive gastropathy is made upon endoscopy where active bleeding from the lesions of PHG or non-removable clots over the lesions is identified. Diagnosis can also be made if the patient has portal hypertension along with the usual gastric lesions and where there is no other bleeding source seen upon complete assessment of the gastrointestinal tract.
Classification of Portal Hypertensive Gastropathy
Classification of Portal Hypertensive Gastropathy is done on the basis of the severity of the condition. A two-category classification system is the most recommended one, which comprises of:
Mild Portal Hypertensive Gastropathy: Where there is only one change in the stomach mucosa, that of appearance of mosaic or snakeskin pattern on it.
Severe Portal Hypertensive Gastropathy: In this, other than the mosaic or snakeskin pattern of the stomach mucosa, there is appearance of bulging or flat red or black-brown spots seen. There also may be active bleeding. The chances of active bleeding and chronic anemia are more in severe PHG.
Diagnosis of Portal Hypertensive Gastropathy
Endoscopy is the common diagnostic test for portal hypertensive gastropathy where the characteristic appearance of stomach mucosa, i.e. mosaic-like or snake skin like appearance of the stomach mucosa, can be seen. There may be presence of red spots also. This pattern is often seen throughout the stomach. Similar type of pattern can be seen in an associated condition known as watermelon stomach or gastric antral vascular ectasia (GAVE), where the difference is that the ectatic blood vessels are more often seen in the lower part of the stomach.
Other than endoscopy, magnetic resonance imaging and computed tomography scan also be done for diagnosis of PHG. Upon CT scan, there is enhancement on the inner layers of the gastric walls seen that can indicate gastric congestion. MRI scan helps in measuring the diameter of the left gastric, azygos and paraesophageal veins, which is not that conclusive in diagnosis of portal hypertensive gastropathy. Proximal part of the stomach which includes the body and fundus is the most common location for portal hypertensive gastropathy.
Esophagogastroduodenoscopy and capsule endoscopy can also be done for diagnosis.
Treatment for Portal Hypertensive Gastropathy
Treatment for portal hypertensive gastropathy depends on the severity of the condition, patient’s symptoms and the rate of bleeding and include:
Medications to Treat Portal Hypertensive Gastropathy: The first line of treatment is medications, such as beta-blockers, which will help in reducing the portal hypertension. Propranolol and nadolol, which are non-selective beta blockers, help in decreasing the portal hypertension in patients who have esophageal varices. These medicines also help in reversing the portal hypertensive gastropathy that is worsened from treatment of varices. Other medications, such as antifibrinolytics, help in treating the bleeding. These medications act by stabilizing the buildup of fibrin at the sites which would bleed. Octreotide can also be used and this medicine causes vasoconstriction of the portal system and helps in reducing the active bleeding occurring as a result of portal hypertensive gastropathy.
Procedural Treatment for Portal Hypertensive Gastropathy: Treatment of portal hypertensive gastropathy can also be done endoscopically where the inside of the stomach is viewed via a fiber-optic camera and electrocautery and Argon Plasma Coagulation (APC) can be done to halt the bleeding from ectatic vessels and along with trying obliteration of the vessels. However these procedures have very limited use or benefit if the disease is diffuse.
Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a procedure for treating portal hypertensive gastropathy which is done under guidance with fluoroscopy. In this procedure, the portal vein is decompressed by shunting a portal venule to a lower pressure systemic venule.
Cryotherapy is another procedure to treat portal hypertensive gastropathy where pressurized carbon dioxide is used to freeze and destroy the tissue in the focal region.