Portal Hypertensive Gastropathy

Portal hypertensive gastropathy (PHG) is a gastric mucosal vasculopathy in portal hypertension, with dilated mucosal and submucosal veins and capillaries, causing chronic bleeding.

• Prevalence 20 to 80% in cirrhosis, rising with duration and severity of portal hypertension (hepatic venous pressure gradient over 10 to 12 mmHg), Child-Pugh class, and after variceal eradication.
• Also in non cirrhotic portal hypertension (portal vein thrombosis, schistosomiasis).
• Mechanism: portal hypertensive congestion, increased gastric blood flow, impaired mucosal defence.
• Severity (McCormack): mild (mosaic like pattern, scarlatina rash, superficial reddening), severe (discrete red spots, black brown spots, diffuse haemorrhage).
• Acute bleeding in 2 to 12%, chronic in 10 to 25% over 3 years in severe PHG; mortality from acute bleeding about 12%.

• Most are asymptomatic.
• Chronic iron deficiency anaemia, melaena, occult bleeding; acute haematemesis in severe disease.
• Signs of cirrhosis and portal hypertension: ascites, splenomegaly, varices, encephalopathy.

• Upper endoscopy: mosaic like (snakeskin) mucosa with polygonal areolae, red marks, cherry red spots, black brown spots, mainly in the fundus and body (differs from GAVE, antral stripes).
• Biopsy not required (bleeding risk); histology shows dilated capillaries and veins without inflammation.
• Laboratory: full blood count, ferritin, liver function, INR, platelets.
• Assess portal hypertension: elastography, hepatic venous pressure gradient, imaging.
• Screen for varices and gastric varices.

• Mild asymptomatic PHG: observation.
• Prevention of bleeding and chronic loss: non selective beta blockers: propranolol 20 to 40 mg twice daily titrated to heart rate 55 to 60 (maximum 160 mg/day with ascites 80 mg), nadolol 20 to 40 mg daily, or carvedilol 6.25 mg daily increasing to 12.5 mg daily (reduces rebleeding by 50 to 65%). Maintain systolic blood pressure over 90 mmHg.
• Iron replacement (oral or IV) for anaemia.
• Acute bleeding: resuscitation (restrictive transfusion, haemoglobin 7 g/dL), vasoactive therapy (octreotide 50 micrograms IV bolus then 50 micrograms/h for 2 to 5 days, or terlipressin 2 mg IV every 4 hours), antibiotic prophylaxis (ceftriaxone 1 g daily for 7 days), proton pump inhibitor, endoscopy to exclude varices.
• Refractory bleeding: TIPS (transjugular intrahepatic portosystemic shunt) reduces PHG bleeding; shunt surgery; liver transplantation as definitive therapy.
• Endoscopic therapy (APC) has limited role, for localised bleeding spots.
• Avoid NSAIDs.
• Monitor haemoglobin; treat the underlying liver disease.