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| {{SI}}
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| {{EH}} | | {{Portal hypertensive gastropathy}} |
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| ==Overview==
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| [[Image:PHGastro.jpg|left|thumb|Image of '''portal hypertensive gastropathy''' seen on [[esophagogastroduodenoscopy|endoscopy]] of the stomach. The normally smooth mucosa of the stomach has developed a mosaic like appearance, that resembles snake-skin.]]
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| '''Portal hypertensive gastropathy''' refers to changes in the [[mucosa]] of the [[stomach]] in patients with [[portal hypertension]]; by far the most common cause of this is [[cirrhosis]] of the [[liver]]. These changes in the mucosa include friability (or fragility) of the mucosa and the presence of ectatic (or unusual) blood vessels at the surface. Patients with portal hypertensive gastropathy may experience bleeding from the [[upper gastrointestinal bleeding|stomach]], which may uncommonly manifest itself in [[hematemesis|vomiting blood]] or [[melena]]; however, portal hypertension may cause several other more common sources of upper gastrointestinal bleeding, such as [[esophageal varices]] and [[gastric varices]]. On endoscopy evaluation of the stomach, this condition shows a characteristic mosaic or "snake-skin" appearance to the mucosa of the stomach.
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| ==Pathogenesis== | | ==[[Portal hypertensive gastropathy overview|Overview]]== |
| Several studies have found that patients with portal hypertension develop increased blood flow to the stomach.<!--
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| --><ref>{{cite journal |author=Iwao T, Toyonaga A, Sumino M, ''et al'' |title=Portal hypertensive gastropathy in patients with cirrhosis |journal=Gastroenterology |volume=102 |issue=6 |pages=2060-5 |year=1992 |pmid=1587424 |doi=}}</ref> <!--
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| --> The physiological findings that correlate with worsening portal hypertensive gastropathy include an increased portal venous pressure gradient and decreased hepatic blood flow.<ref>{{cite journal |author=Gupta R, Sawant P, Parameshwar RV, Lele VR, Kulhalli PM, Mahajani SS |title=Gastric mucosal blood flow and hepatic perfusion index in patients with portal hypertensive gastropathy |journal=J. Gastroenterol. Hepatol. |volume=13 |issue=9 |pages=921-6 |year=1998 |pmid=9794191 |doi=}}</ref> [[Biopsy|Biopsies]] of the stomach in patients with portal hypertensive gastropathy show ectatic (or dilated) blood vessels, evidence of bleeding by means of red blood cells in the [[lamina propria]], and [[edema]] in the stomach wall.<ref name=PHGrev>{{cite journal |author=Thuluvath PJ, Yoo HY |title=Portal Hypertensive gastropathy |journal=Am. J. Gastroenterol. |volume=97 |issue=12 |pages=2973-8 |year=2002 |pmid=12492178 |doi=}}</ref>
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| ==Clinical findings== | | ==[[Portal hypertensive gastropathy historical perspective|Historical Perspective]]== |
| Most patients with portal hypertensive gastropathy have either a stable or improving course in the appearance of the gastropathy on [[esophagogastroduodenoscopy|endoscopy]]. However, according to retrospective data, roughly one in seven patients with portal hypertensive gastropathy will develop bleeding (either acute or chronic) attributable to the gastropathy.<ref>{{cite journal |author=Primignani M, Carpinelli L, Preatoni P, ''et al'' |title=Natural history of portal hypertensive gastropathy in patients with liver cirrhosis. The New Italian Endoscopic Club for the study and treatment of esophageal varices (NIEC) |journal=Gastroenterology |volume=119 |issue=1 |pages=181-7 |year=2000 |pmid=10889167 |doi=}}</ref> Patients with chronic bleeding will usually come to the attention of the medical system because of [[anemia]].
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| The diagnosis of portal hypertensive gastropathy is usually made on endoscopy. The usual appearance of portal hypertensive gastropathy on endoscopy is a mosaic-like or reticular pattern in the mucosa. Red spots may or may not be present. The pattern is usually seen throughout the stomach.<ref name=PHGrev/> A similar pattern can be seen with a related condition called [[gastric antral vascular ectasia]] (GAVE), or watermelon stomach. However, in GAVE, the ectatic blood vessels are more commonly found in the [[antrum]] or lower part of the stomach.<ref name=PHGrev/>
| | ==[[Portal hypertensive gastropathy pathophysiology|Pathophysiology]]== |
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| ==Treatment== | | ==[[Portal hypertensive gastropathy causes|Causes]]== |
| [[Image:Gave.png|thumb|left|Argon plasma coagulation, seen here to treat [[gastric antral vascular ectasia]], has also been used to treat bleeding from portal hypertensive gastropathy]]
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| ===Medications=== | | ==[[Portal hypertensive gastropathy differential diagnosis|Differentiating Portal Hypertensive Gastropathy from other Diseases]]== |
| Several treatment options have been developed for portal hypertensive gastropathy. The first is the use of [[beta-blockers]], which reduce portal pressures. Non-selective beta blockers (such as [[propranolol]] and [[nadolol]] have been used to decrease the pressure of the portal vein in patients with [[esophageal varices]], and have been shown to regress portal hypertensive gastropathy that has been worsened by medical treatment of varices.<ref>{{cite journal |author=Lo GH, Lai KH, Cheng JS, ''et al'' |title=The effects of endoscopic variceal ligation and propranolol on portal hypertensive gastropathy: a prospective, controlled trial |journal=Gastrointest. Endosc. |volume=53 |issue=6 |pages=579-84 |year=2001 |pmid=11323582 |doi=}}</ref> [[Propranolol]] has also been evaluated in patients with chronic cirrhosis and portal hypertensive gastropathy <ref>{{cite journal |author=Pérez-Ayuso RM, Piqué JM, Bosch J, ''et al'' |title=Propranolol in prevention of recurrent bleeding from severe portal hypertensive gastropathy in cirrhosis |journal=Lancet |volume=337 |issue=8755 |pages=1431-4 |year=1991 |pmid=1675316 |doi=}}</ref> Other medications that primarily treat bleeding, including anti-fibrinolytic medications such as [[tranexamic acid]] have also been used in case reports of patients with portal hypertensive gastropathy.<ref>{{cite journal |author=McCormick PA, Ooi H, Crosbie O |title=Tranexamic acid for severe bleeding gastric antral vascular ectasia in cirrhosis |journal=Gut |volume=42 |issue=5 |pages=750-2 |year=1998 |pmid=9659175 |doi=}}</ref> These medications work by stabilizing deposits of [[fibrin]] at sites that ordinarily would bleed.
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| | ==[[Portal hypertensive gastropathy epidemiology and demographics|Epidemiology and Demographics]]== |
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| Finally, [[octreotide]], an analogue of [[somatostatin]] that leads to vasoconstriction of the portal circulation, can be used for active bleeding due to portal hypertensive gastropathy.<ref name=Rev2>{{cite journal |author=Garcia N, Sanyal AJ |title=Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia |journal= |volume=4 |issue=2 |pages=163-171 |year=2001 |pmid=11469974 |doi=}}</ref> [[Sucralfate]], a coating medication has also been used, but evidence is from animal models.<ref>{{cite journal |author=Geoffroy P, Duchateau A, Thiéfin G, Zeitoun P |title=Effects of propranolol and sucralfate on ethanol-induced gastric mucosal damage in chronic portal hypertensive rats |journal=J. Hepatol. |volume=5 |issue=2 |pages=162-6 |year=1987 |pmid=3693860 |doi=}}</ref>
| | ==[[Portal hypertensive gastropathy risk factors|Risk Factors]]== |
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| ===Procedural=== | | ==[[Portal hypertensive gastropathy natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| Portal hypertensive gastropathy can also be treated with endoscopic treatment delivered through a fibre-optic camera into the stomach. [[Argon plasma coagulation]] and electrocautery have both been used to stop bleeding from ectatic vessels, and to attempt to obliterate the vessels, but have limited utility if the disease is diffuse.<ref>{{cite journal |author=Sato T, Yamazaki K, Toyota J, ''et al'' |title=Efficacy of argon plasma coagulation for gastric antral vascular ectasia associated with chronic liver disease |journal=Hepatol. Res. |volume=32 |issue=2 |pages=121-6 |year=2005 |pmid=15967712 |doi=10.1016/j.hepres.2005.04.004}}</ref><ref name=Rev2/> | |
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| [[TIPS|Transcutaneous intrahepatic portosystemic shunt]] procedures, or TIPS involve decompressing the portal vein by shunting a portal venule to a lower pressure systemic venule, under guidance with [[fluoroscopy]]. Since it treats the root cause of portal hypertension gastropathy, it has been putatively used for the condition. The literature reports suggest both regression of portal hypertensive gastropathy on [[endoscopy|endoscopic]] images and improvement in bleeding after TIPS.<ref>{{cite journal |author=Urata J, Yamashita Y, Tsuchigame T, ''et al'' |title=The effects of transjugular intrahepatic portosystemic shunt on portal hypertensive gastropathy |journal=J. Gastroenterol. Hepatol. |volume=13 |issue=10 |pages=1061-7 |year=1998 |pmid=9835325 |doi=}}</ref> | | ==Diagnosis== |
| | [[Portal hypertensive gastropathy history and symptoms| History and Symptoms]] | [[Portal hypertensive gastropathy physical examination | Physical Examination]] | [[Portal hypertensive gastropathy laboratory findings|Laboratory Findings]] | [[Portal hypertensive gastropathy CT|CT]] | [[Portal hypertensive gastropathy MRI|MRI]] | [[Portal hypertensive gastropathy ultrasound|Ultrasound]] | [[Portal hypertensive gastropathy other imaging findings|Other Imaging Findings]] | [[Portal hypertensive gastropathy endoscopy|Endoscopy]] |
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| Finally, [[cryotherapy]] involves the use of pressurized [[carbon dioxide]] administered through the endoscope to freeze and destroy tissue in a focal area. It is being studied for the treatment of portal hypertensive gastropathy.<ref>{{cite journal |author=Clarke JO, Thuluvath PJ |title=Endoscopic frontiers in the field of hepatology |journal=Minerva gastroenterologica e dietologica |volume=53 |issue=1 |pages=101-9 |year=2007 |pmid=17415347 |doi=}}</ref>
| | ==Treatment== |
| | [[Portal hypertensive gastropathy medical therapy|Medical Therapy]] | [[Portal hypertensive gastropathy primary prevention|Primary Prevention]] | [[Portal hypertensive gastropathy secondary prevention|Secondary Prevention]] | [[Portal hypertensive gastropathy cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Portal hypertensive gastropathy future or investigational therapies|Future or Investigational Therapies]] |
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| ==Similar conditions== | | ==Case Studies== |
| Congestion of the mucosa in other parts of the gastrointestinal tract can also be seen in portal hypertension. When the condition involves the colon, it is termed ''portal hypertensive colopathy''.<ref>{{cite journal |author=Bini EJ, Lascarides CE, Micale PL, Weinshel EH |title=Mucosal abnormalities of the colon in patients with portal hypertension: an endoscopic study |journal=Gastrointest. Endosc. |volume=52 |issue=4 |pages=511-6 |year=2000 |pmid=11023569 |doi=}}</ref>
| | [[Portal hypertensive gastropathy case study one|Case#1]] |
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| == References == | | ==Related Chapters== |
| <div class="references-small" style="-moz-column-count:2; column-count:2;">
| | [[Portal Hypertension]] |
| <references />
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| </div>
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| {{SIB}}
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| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
| | [[Category:Disease]] |
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| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |