Skip to main page content
Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
, 8 (4), 231-62

Portal Hypertensive Gastropathy: A Systematic Review of the Pathophysiology, Clinical Presentation, Natural History and Therapy

Affiliations

Portal Hypertensive Gastropathy: A Systematic Review of the Pathophysiology, Clinical Presentation, Natural History and Therapy

Mihajlo Gjeorgjievski et al. World J Hepatol.

Abstract

Aim: To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy (PHG) based on a systematic literature review.

Methods: Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "portal" and "gastropathy"; or "portal" and "hypertensive"; or "congestive" and "gastropathy"; or "congestive" and "gastroenteropathy". The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG.

Results: PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG. PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepatic-portosystemic-shunt and liver transplantation are highly successful ultimate therapies because they reduce the underlying portal hypertension.

Conclusion: PHG is important to recognize in patients with cirrhotic or non-cirrhotic portal hypertension because it can cause acute or chronic GI bleeding that often requires pharmacologic therapy.

Keywords: Chronic liver disease; Cirrhosis; Cirrhotic; Congestive gastropathy; Esophageal varices; Hepatic fibrosis; Nonvariceal upper gastrointestinal bleeding; Portal hypertension; Portal hypertensive gastropathy.

Figures

Figure 1
Figure 1
Hypothesized mechanism of portal hypertensive gastropathy. 1The finding of decreased gastric mucosal perfusion in PHG is somewhat controversial (see text). PHG: Portal hypertensive gastropathy.
Figure 2
Figure 2
A 60-year-old man presented for routine endoscopic screening for esophageal varices due to a history of Child-Pugh class B cirrhosis, with a model for end-stage liver disease score = 18, from hepatitis C secondary to former intravenous drug use. The patient denied a history of gastrointestinal bleeding. The hematocrit was 40.1%. Esophagogastroduodenoscopy revealed the classic findings of portal hypertensive gastropathy, including a pale white reticular (mosaic) pattern surrounding small polygonal areas of mucosa, with variable erythema, in the entire stomach, but most prominently in the gastric fundus and body. B is a relatively close-up view of the lesions seen in A.

Similar articles

See all similar articles

Cited by 16 PubMed Central articles

See all "Cited by" articles
Feedback