Portal hypertensive gastropathy (PHG) is a condition that occurs in patients with portal hypertension. Portal hypertension is when blood pressure increases in a system of veins known as the portal venous system, which are the veins that come from the stomach, intestines, spleen, and pancreas and merge into the portal vein.
PHG results in changes in the stomachs mucosa, which will appear in a mosaic-like pattern. Other changes include the presence of blood vessels ectasia. Patients may experience bleeding of the stomach, which may be present in vomit or stool. The most common cause of portal hypertensive gastropathy is cirrhosis of the liver.
Types of portal hypertensive gastropathy
Portal hypertensive gastropathy can be classified based on its severity. The New Italian Endoscopic Club for the Study and Therapy of Esophageal Varices [NIEC] and Tanoue classify PHG into three categories including mild, moderate, and severe based on endoscopic identifications. McCormack’s only has two classifications, which is most widely recognized.
The two classifications include mild and severe. Mild PHG is when the patient has changes in the gastric mucosa that appears snake-like or mosaic-like. Severe PHG will not only have the changes in stomach mucosa, but the appearance of black-brown and flat or bulging red spots along with acute bleeding. There is a higher risk of hemorrhaging in severe PHG and it may even contribute to chronic anemia.
Epidemiology of portal hypertensive gastropathy
As mentioned, the main cause of PHG is cirrhosis of the liver. Roughly 65 percent of patients with portal hypertension will go on to develop PHG, and it’s far more common in patients who also have liver disease. PHG is more prevalent among people with esophageal varices.
It is still unclear what the pathological process of PHG is. Important factors that can contribute to it are the excess production of prostaglandins, tumor necrosis factor, epidermal development factors, and increases in the level of gastric nitric oxide. PHG may also result in thrombosis of the portal vein. H. pylori infection has also been linked to a higher risk of PHG.
Symptoms of portal hypertensive gastropathy
Many patients of portal hypertensive gastropathy are asymptomatic, but one in seven patients will experience acute or chronic bleeding.
The majority of patients will have symptoms related to gastrointestinal bleeding and chronic anemia—iron deficiency. Some patients will have symptoms related to only active gastrointestinal bleeding. Chronic bleeding contributes to anemia, which can trigger symptoms like fatigue, rapid heartbeat, shortness of breath, headache, dizziness, pale skin, leg cramps, and insomnia.
To determine chronic bleeding, a patient must experience a hemoglobin loss of about 2g/dL within six months without the use of anti-inflammatory drugs and without symptoms related to chronic bleeding.
Acute gastrointestinal bleeding is less common, and diagnosis is made with an endoscopy, where active bleeding from the lesions of PHG or non-removable clots over the lesions are identified.
Diagnosis of portal hypertensive gastropathy
The most common diagnostic method of portal hypertensive gastropathy is with an endoscopy, which is inserted through the mouth and put down into the stomach. This allows doctors to see the stomach mucosa and check for any changes such as a snake-like or mosaic appearance. This type of pattern is also seen in conditions like watermelon stomach or gastric antral vascular ectasia (GAVE), but the main difference is more visible ecstatic blood vessels in the lower part of the stomach.
Aside from endoscopy, your doctor may also utilize MRI and CT scans. A CT scan can reveal the inner layers of the gastric walls, which can signal congestion. MRI can help measure the diameter of the left gastric, azygos, and paraesophageal veins.
Esophagogastroduodenoscopy and capsule endoscopy are other methods of diagnosis for PHG.
How to treat portal hypertensive gastropathy
The severity, symptoms, and rate of bleeding of PHG will determine treatment. Medications can be prescribed to treat PHG, which include beta-blockers to help reduce portal hypertension. This treatment may also help prevent PHG from worsening. Other medications include antifibrinolytics to treat bleeding. Lastly, octreotide can reduce active bleeding.
Procedures to treat PHG are done endoscopically and Argon Plasma Coagulation (APC) is carried out, which halts bleeding.
Transjugular Intrahepatic Portosystemic Shunt (TIPS) may also be performed, which decompresses the portal vein by shunting a portal venule to a lower pressure venule.