Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

Table 1 Rates of portal hypertensive gastropathy in patients with portal hypertension

Ref.	Analyzed patients	Total number	No. (%) with PHG	No. (%) with mild PHG	No. (%) with severe PHG
McCormack et al[3]	Portal hypertension	127	65 (51%)	37 (29%)	28 (22%)
Sarin et al[5]	Portal hypertension	136	10 (7%)
DeWeert et al[6]	Non-alcoholic liver disease	81	23 (28%)	Not reported	Not reported
McCormick et al[7]	Portal hypertension	93 endoscopies in 74 patients	85 endoscopies (91%)	6 (6%), moderate 61 (66%)	18 (19%)
Sarin et al[8]	Portal hypertension	107	4 (3.7%) (only cirrhotic)	Not reported	Not reported
Parikh et al[9]	Portal hypertension	118	71 (60%)	41 (58%)	30 (42%)
Sarin et al[10]	Portal hypertension with prior variceal bleeding	967	86 (9%)	56 (5.8%)	30 (3.1%)
Itha et al[11]	EHPVO in children	163	(12%)	Not reported	Not reported
Rana et al[12]	Portal hypertension	41	27 (66%)	19 (46%)	8 (20%)
El-Rifai et al[13]	Portal hypertension	24	14 (58%)	10 (42%) - moderate	4 (16%)
Sogaard et al[14]	Portal vein thrombosis	67	28 (42%)	Not reported	Not reported
Figueiredo et al[15]	Portal hypertension; cirrhosis	36	27 (75%)		5 (46%)
Erden et al[16]	Portal hypertension	57	15 (26.3%)	Not reported	Not reported
Duché et al[17]	Children, portal hypertension with biliary atresia	125	27 (21%)	Not reported	Not reported
Aydoğan et al[18]	Portal hypertension	51	30 (58%)	Not reported	Not reported
dos Santos et al[19]	Portal hypertension	43	22 (51%)	Not reported	Not reported
Pantham et al[20]	Esophageal varices undergoing TEE	24	12 (50%)	Not reported	Not reported
Abdollahi et al[21]	Autoimmune hepatitis	60	27 (45%)	Not reported	Not reported
de Alcantara et al[22]	Chronic liver disease vs EHPVO	35 vs 18	7 (20%) vs 8 (44.4%)	Not reported	Not reported
Aoyama et al[23]	Portal hypertension	119	35 (29%)	Not reported	Not reported

PHG: Portal hypertensive gastropathy; EHPVO: Extrahepatic portal vein obstruction; TEE: Transesophageal echocardiogram.

Table 2 Rates of portal hypertensive gastropathy in patients with cirrhosis

Ref.	Patients	Total number	PHG	Mild	Severe
Sacchetti et al[24]	Cirrhosis	142	38 (27%)	28 (20%)	10 (7%)
D'Amico et al[25]	Cirrhosis	212	130 (61%)	110 (52%)	20 (9%)
Calès et al[26]	Cirrhosis	100	98 (98%)	57 (57%)	41 (41%)
Rabinovitz et al[27]	Cirrhosis	510	(43%)	Not reported	Not reported
Iwao et al[28]	Cirrhosis	47	32 (68%)	15 (32%)	17 (36%)
Taranto et al[29]	Cirrhosis	394	317 (80.5%)	Not reported	Not reported
Gupta et al[30]	Cirrhosis	230	(61%)	(52%)	(9%)
Iwao et al[31]	Cirrhosis	476	254 (53%)	208 (43%)	46 (9%)
Carpinelli et al[32]	Cirrhosis	566	362 (64%)	192 (34%)	170 (30%)
Zaman et al[33]	Cirrhosis	120	74 (62%)	47 (39%)	27 (23%)
Primignani et al[34]	Cirrhosis	373	299 (80%)	127 (34%)	172 (46%)
Chaves et al[35]	Cirrhosis vs schistosomiasis	43	18 (81%) vs 7 (33%)	Not reported	Not reported
Merkel et al[36]	Cirrhosis	62	49 (79%)	29 (46%)	20 (32%)
Merli et al[37]	Cirrhosis, with mild portal hypertension	222	48 (21%)	43 (19%)	5 (2%)
Ito et al[38]	Cirrhosis	47	13 (27%)	10 (21%)	3 (6%)
De Palma et al[39]	Cirrhosis	37	23 (62%)	Not reported	Not reported
Menchén et al[40]	Cirrhosis	549	353 (64%)	275 (50%)	77 (14%)
Yüksel et al[41]	Cirrhosis	114 total	76 (66%)	38 (33%)	38 (33%)
Fontana et al[42]	Cirrhosis or bridging fibrosis from hepatitis C	1016	374 (37%)	345 (34%)	29 (3%)
Bresci et al[43]	Cirrhosis	85	36 (42%)	Not reported	Not reported
Akatsu et al[44]	End stage liver disease	29	19 (65.5%)	18 (62.1%)	1 (3.4%)
Zardi et al[45]	Cirrhosis	266	84 (31%)	Not reported	Not reported
Barakat et al[46]	Cirrhosis with portal hypertensive duodenopathy	105	105 (100%)	17 (16.2%)	88 (83.8%)
Bellis et al[47]	Cirrhosis	59	44 (76%)	16 (27%)	28 (47%)
Gravante et al[48]	Liver transplant candidates with cirrhosis	80	41 (51.2%)	Not reported	Not reported
Canlas et al[49]	Cirrhosis	19	13 (68.4%)	Not reported	Not reported
Kim et al[50]	Cirrhosis	83	48 (57.8%)	Not reported	Not reported
Higaki et al[51]	Cirrhosis	21	8 (38%)	Not reported	Not reported
Frenette et al[52]	Cirrhosis	50	45 (90%)	28 (56%)	17 (34%) moderate
Tarantino et al[53]	Cirrhosis	153	88 (57.5%)	Not reported	Not reported
Curvêlo et al[54]	Cirrhosis	46	43 (93.4%)	21 (45%)	22 (47%)
Anegawa et al[55]	Cirrhosis	70	49 (70%)	32 (46%)	17 (24%)
Kumar et al[56]	Cirrhosis	254	140 (55%)	Not reported	Not reported
Kim et al[57]	Cirrhosis	331	298 (90%)	Mild 84 (25.4%)	214 (64.7%)
De Lisi et al[58]	Cirrhosis	611	448 (73.3%)	37.3%	36%
Abbasi et al[59]	Cirrhosis	102	87 (85%)	Not reported	Not reported
Ahmed et al[60]	Cirrhosis from hepatitis B or hepatitis C	360	300 (83%)	229 (64%)	71 (20%)
Garcia-Saenz-de-Sicilia et al[61]	Cirrhosis	105	72 (68.6%)	Not reported	Not reported
Abbasi et al[62]	Cirrhosis	217	172 (79.3%)	56 (25.8%)	116 (53.5%)
Aoyama et al[63]	Cirrhosis	60	13 (22%)	Not reported	Not reported
Laleman et al[64]	Cirrhosis with refractory chronic hepatic encephalopathy	36	13 (36%)	9 (25%)	4 (11%)
Giannini et al[65]	Cirrhosis and undergoing surgery for hepatocellular carcinoma	152	23 (15.1%)	Not reported	Not reported
Abdollahi et al[21]	Autoimmune hepatitis	60	27 (45%)	Not reported	Not reported
Aoyama et al[23]	Portal hypertension	119	35 (29%)	Not reported	Not reported
Aoyama et al[66]	Cirrhosis	134	42 (31%)	Not reported	Not reported
Zardi et al[67]	Cirrhosis without gastroesophageal varices	145	75 (51%)	45 (31%)	30 (20%)
Wu et al[68]	Cirrhosis	700	449 (64%)	Mild 208 (29.7), moderate 160 (22.9%)	Severe 81 (11.6%)

PHG: Portal hypertensive gastropathy.

Table 3 Effects of variceal ligation on frequency of portal hypertensive gastropathy

Ref.	No. of patients and etiology	Study type	PHG rate before variceal ligation	PHG aggravation after variceal ligation	P value of pre vs post EVL
Hou et al[73]	90 patients with cirrhosis and recent variceal bleeding, 46 patients underwent EVL	Randomized, controlled trial	No PHG-4, mild PHG-33, severe-PHG-9	At eradication: 17/37; 17/37 (45.9%) in EVL; at 3 mo: 17/30 (56.7%); at 6 mo 18/29 (62.1%)	P > 0.05
Elnaser et al[80]	125 patients with upper GI bleeding undergoing variceal ligation, followed for mean of 31 mo	Retrospective study	22/125 (17.6%)	50/125 (50%)	P < 0.05
Yüksel et al[41]	114 patients with cirrhosis and portal hypertension undergoing EVL in 85 patients	Retrospective study	27/85 (31.8%) none; 28/85 (32.9%) mild; 30/85 (35.3%) severe	14/85 (16.5%) none; 30/85 (35.3%) mild; 41/85 (48.2%) severe	P < 0.05
Lo et al[81]	77 patients with bleeding from EV underwent variceal ligation and were randomized to receive propranolol (37/77) or control (40/77); patients with severe PHG prior to treatment excluded from the study	Prospective, randomized, controlled trial	Control group: 7/40 (17%); propranolol group: 8/37 (22%)	At variceal ligation: Control group: 67% (does not state number); Propranolol group: 31% (number not stated); 6 mo after treatment: Control group: 85% (number not stated) propranolol group: 48% (number not stated)	Pre vs post ligation, both groups; P < 0.05; frequency of PHG significantly higher in control group post ligation when compared to propranolol group; P = 0.002
de la Peña et al[82]	93 patients with history of variceal hemorrhage and cirrhosis, randomized to receive either EVS (46/88) or EVL (42/88); 5 patients excluded due to diagnosis of hepatoma, non-cirrhotic portal hypertension or portal vein thrombosis	Randomized, prospective study	Not reported	PHG significantly worsened in 23 patients, including 17 patients undergoing EVL	P < 0.01

PHG: Portal hypertensive gastropathy; EVL: Endoscopic variceal ligation; EVS: Endoscopic variceal sclerotherapy.

Table 4 Effects of variceal sclerotherapy on frequency of portal hypertensive gastropathy

Ref.	No. of patients and etiology	Study type	PHG before procedure	PHG aggravation after procedure	P value
Hou et al[73]	90 cirrhotic patients with recent variceal bleeding; EVS 44, EVL 46	Randomized, controlled trial	Pre EVS group: 6 none/24 mild/14 severe; pre EVL group: 4 none/33 mild/9 severe; total: 10 none/57 mild/23 severe	At eradication: 14/29 (48.3%) in EVS; 17/37 (45.9%) in EVL; at 3 mo: 15/26 (57.7%) in EVS; 17/30 (56.7%) in EVL; at 6 mo 15/25 (60%) in EVS; 18/29 (62.1%) in EVL	Non-significant difference in PHG aggravation between EVS and EVL; P > 0.05
Itha et al[11]	163 children with extrahepatic portal vein obstruction presenting with variceal bleeding underwent endoscopic injection sclerotherapy	Not reported	12% overall PHG (actual number not stated), 1 patient with severe PHG	41% overall PHG (actual number not stated), 12 patients with severe PHG	P < 0.001 for overall PHG; P < 0.001 for severe PHG
Poddar et al[83]	186 children with extrahepatic portal vein obstruction presenting with variceal bleeding undergoing endoscopic sclerotherapy, and mean follow up of 38 ± 30 mo	Retrospective study	PHG: 46/186 (24.7%), severe PHG: 6/186 (3.2%)	PHG: 96/186 (51.6%), severe PHG: 29/186 (15.6%)	P < 0.001 for overall PHG; P < 0.05 for severe PHG
Yüksel et al[41]	114 patients with cirrhosis and portal hypertension undergoing EVS (29/114) or EVL (85/114)	Retrospective study	Pre EVS group: 11/29 (37.9%) none; 10/29 (24.5%) mild; 8/29 (27.6%) severe; pre EVL group: 27/85 (31.8%) none; 28/85 (32.9%) mild; 30/85 (35.3%) severe	Post EVS group: 4/29 (13.8%) none; 8/29 (27.6%) mild; 17/29 (58.6%) severe; post EVL group: 14/85 (16.5%) none; 30/85 (35.3%) mild; 41/85 (48.2%) severe	Pre EVS vs post EVS; P < 0.05; pre EVL vs post EVL; P < 0.05; pre EVS vs pre EVL; P > 0.05; post EVS vs post EVL; P > 0.05
Sarin et al[10]	967 patients with variceal bleeding underwent endoscopic sclerotherapy; out of whom 88 patients fulfilled the inclusion criteria (including presence of endoscopic lesions consistent with PHG or GAVE, before or within 4 wk after obliteration) were prospectively followed (out of whom 2 had only GAVE)	Prospective study	22 patients had PHG prior to EVS; 2/22 transient (9%); 17/22 persistent (77%); 3/22 progressive (14%)	Additional development in 64 patients post procedure, 28/64 transient (44%), 31/64 persistent (48%), 5/64 progressive (8%)	Only statistically significant difference was the transient PHG that disappeared in 28 (44%) of patients in the group that developed PHG post procedure; P < 0.05
Gupta et al[30]	230 patients with liver cirrhosis; of which 44 underwent variceal eradication with sclerotherapy	Prospective study	24/44 (54%)	33/44 (75%)	P < 0.05
Sarin et al[8]	107 patients with portal hypertension presenting with variceal bleeding that underwent sclerotherapy with mean follow-up of 23.2 ± 3.4 mo	Prospective study	4/107 (3.7%)	21 additional patients, 25/107 (23%)	Does not state if this was statistically significant
de la Peña et al[82]	93 patients with history of variceal hemorrhage and cirrhosis, randomized to receive either EVS (46/88) or EVL (42/88); 5 patients were excluded due to diagnosis of hematoma, non-cirrhotic portal hypertension or portal vein thrombosis	Prospective study	Not reported	PHG worsened in 23 patients total; statistically significantly more in EVL group than EVS group (17 vs 6 patients respectively)	P < 0.01
D'Amico et al[25]	212 cirrhotic patients of which 75 had an episode of variceal bleeding and were treated with sclerotherapy; 137 without bleeding were not treated with sclerotherapy	Prospective study	No EVS group at admission: 104/137 (75%) none; 28/137 (20%) mild; 5/137 (4%) severe; EVS group at admission: 50/75 (66%) none; 17/75 (22%) mild; 8/75 (11%) severe	No EVS group at end of study 69/137 (50%) none; 61/137 (45%) mild; 7/137 (5%) severe; EVS group at end of study: 13/75 (17%) none; 49/75 (65%) mild; 13/75 (17%) severe	The conclusion was that sclerotherapy is a significant indicator of the risk of PHG in a multivariate analysis (P = 0.00032)

PHG: Portal hypertensive gastropathy; EVL: Endoscopic variceal ligation; EVS: Endoscopic variceal sclerotherapy.

Table 5 Well-established, important risk factors for portal hypertensive gastropathy

Parameters	Ref.
Portal hypertension
Non-cirrhotic portal hypertension	[8,14]
Cirrhotic portal hypertension	[8,9,34]
Cirrhosis
Longer duration of cirrhosis	[34,71]
Greater severity of cirrhosis	[55,67]
Greater size of esophageal varices	[34,62]
Eradication of esophageal varices
Endoscopic therapies
Endoscopic variceal ligation	[11,41]
Endoscopic sclerotherapy	[11,83]
Angiographic
Percutaneous transhepatic variceal embolization	[85]

Table 6 Therapies affecting the severity or the risk of bleeding from portal hypertensive gastropathy

Therapies reducing severity of PHG	Ref.
TIPS	[76,77,98]
Transcatheter splenic arterial embolization	[99]
Surgical shunt
Portocaval shunt	[100]
Central splenorenal shunt	[101]
Laparoscopic splenectomy (in patients with hypersplenism)	[55]
Liver transplantation	[44]
Therapies reducing risk of bleeding from PHG
TIPS	[75,98,102]
Surgical shunt (portocaval or splenorenal)	[100,101]
Nonselective b β-adrenergic receptor antagonists (e.g., propranolol)	[103 (in rats),104]
Somatostatin family of drugs
Somatostatin	[105]
Octreotide	[106]
Vasopressin family of drugs
Vasopressin	[106]
Terlipressin	[107]
Therapies that increase incidence or risk of bleeding from PHG
Endoscopic therapies for varices
Variceal ligation	[11,41]
Variceal sclerotherapy	[11,83]
Interventional angiography
Percutaneous transhepatic variceal embolization	[85]

TIPS: Transjugular intrahepatic portosystemic shunt; PHG: Portal hypertensive gastropathy.

Table 7 Factors not affecting risk of portal hypertensive gastropathy

Factors not affecting risk of portal hypertensive gastropathy	Ref.
Etiology of cirrhosis	[8,28,30]
Etiology of non-cirrhotic portal hypertension	[8,14,35,83,108]
Alcoholism	[30,42]
NSAID use	[42]
Use of COX-2 inhibitors	[42]
Smoking tobacco	[42]
Gastric infection with Helicobacter pylori	[109,110]

NSAID: Nonsteroidal anti-inflammatory drug; COX-2: Cyclooxygenase-2.

Table 8 Different classification systems for portal hypertensive gastropathy

Ref.	Mild	Moderate	Severe
McCormack et al[3]	Fine pink speckling (scarlatina type rash)		Discrete red spots (analogous to cherry
	Superficial reddening, especially on rugal surface (striped appearance)		red spots in esophagus)
	Fine white reticular pattern separating areas of raised edematous mucosa (snake skin)		Diffuse hemorrhagic gastritis
McCormick et al[7]	Mosaic or snake skin appearance	Presence of erythema	Presence of erosions or hemorrhagic gastritis
Tanoue et al[180]	Mild reddening, congestive mucosa, no mosaic - like pattern	Severe redness and a fine reticular pattern separating the areas of raised edematous mucosa (mosaic-like pattern) or a fine speckling	Grade III (severe)
			Point bleeding + grade II (moderate)
Spina et al[70] (NIEC)	Mosaic-pattern: Presence of small,		Red point lesions (1 mm in diameter, flat)
	polygonal areas surrounded by a		Cherry-red spots (2 mm, slight protrusion)
	whitish-yellow depressed border		Black-brown spots (irregularly shaped, persistently present after washing)
Sarin et al[8]	Discrete cherry red spots, with or without mosaic pattern		Presence of confluent red spots, diffusely distributed in a large portion of the stomach
Sarin et al[181] (Baveno II Consensus Workshop)[181]	Mild ≤ 3 points1		Severe ≥ 4 points1
			Gastric antral ectasia
			Absent (0)
			Present (2)
Yoo et al[182]	Fine pink speckling (scarlatina type rash)		Discrete red spots
2-category classification	Superficial reddening		Diffuse hemorrhagic lesion
	Mosaic pattern
Yoo et al[182]	Mild reddening	Flat red spot in center of a pink areola	Diffusely red areola
3-category classification	Congestive mucosa	Severe redness and a fine reticular pattern	Pinpoint bleeding
	Diffuse pink areola		Discrete or confluent red mark lesion

¹Points assigned for Baveno II consensus according to the following: Mild mucosal mosaic pattern = 1 point, severe mucosal mosaic pattern = 2 points; isolated red markings = 1 point, confluent red markings = 2 points; gastric antral ectasia present = 2 points.

Table 9 Differences between portal hypertensive gastropathy and gastric antral vascular ectasia

Parameter	Portal hypertensive gastropathy	Gastric antral vascular ectasia	Ref.
Associated conditions	Conditions associated with portal hypertension: cirrhotic or non-cirrhotic portal hypertension	Cirrhosis, autoimmune disorders, and connective tissue diseases (scleroderma, pernicious anemia, hypothyroidism)	[72]
Association with portal hypertension	Strong association	Only 30% of cases	[191,192]
Sex	Mildly more common in males (alcoholic cirrhosis more common in males than females)	Much more common in females (80%)	[193,194]
Age	Can occur at any age in patients with portal hypertension or cirrhosis	Typically elderly (average age > 70 years old)
Location	Proximal stomach: Fundus, body	Distal stomach: Antrum	[72,192]
Diagnosis	Endoscopy (endoscopic biopsy sometimes useful). Radiologic imaging usually not helpful	Endoscopy (endoscopic biopsy sometimes useful)	[72,195]
Appearance at endoscopy	Mosaic/snakeskin mucosa with red or brown spots	Tortuous columns of ectatic vessels in "watermelon" or diffuse pattern; erythematous or hemorrhagic	[191]
Histology	Ectatic capillaries, mildly dilated mucosal and submucosal veins; no vascular inflammation, no vascular thrombi	Marked dilation of capillaries and venules in gastric mucosa and submucosa with areas of intimal thickening, fibrin thrombi, fibromuscular hyperplasia and spindle cell proliferation	[72,191,196,197]
Clinical presentation/ complications	Gastrointestinal bleeding: Usually chronic, but sometimes acute	Almost exclusively chronic gastrointestinal bleeding with guaiac positive stools	[37,193]
Primary prophylaxis	Not indicated	Not indicated (unless associated with large varices)	[198]
Medical therapy	Non-selective β-adrenergic receptor antagonists (propranolol), octreotide (for acute bleeding)	No benefit of β-adrenergic receptor antagonists	[103,106,198-201]
		Oral contraceptive pills to temporarily control bleeding
		Questionable benefit of octreotide
Endoscopic therapy	Occasionally helpful (for focal bleeding)	Very helpful at reducing risk of bleeding: Argon plasma coagulation; EBL; Radiofrequency ablation; YAG laser therapy	[202-207]
	Argon plasma coagulation
	Local hemostasis with hemospray
TIPS	Significantly reduces severity and risk of bleeding by reducing portal hypertension. Option for very severe bleeding from PHG or for moderate PHG in patients with variceal bleeding	Not recommended. Does not affect severity of GAVE or risk of bleeding	[75,77]
Liver transplantation	Resolves. Ultimate therapy mostly reserved for patients with end-stage liver disease	Improves or resolves with liver transplantation	[75,200,208-210]
Other surgery	Usually resolves with shunt surgery that lowers portal pressure. Partial gastrectomy not recommended	Limited surgical resection (partial gastrectomy) recommended for refractory cases. Shunt surgery not recommended	[75,200,211-213]
Prognosis from bleeding	Bleeding rarely severe and very rarely fatal	Bleeding occasionally severe	[34,71,72]

YAG: Yttrium aluminum garnet; TIPS: Transjugular intrahepatic portosystemic shunt; PHG: Portal hypertensive gastropathy; GAVE: Gastric antral vascular ectasia; EBL: Endoscopic band ligation.

Table 10 Differences in gastrointestinal bleeding from portal hypertensive gastropathy vs esophageal varices

Parameter	Portal hypertensive gastropathy	Esophageal varices
Etiology	Portal hypertension: Cirrhotic or non-cirrhotic	Portal hypertension: Cirrhotic or non-cirrhotic
Concurrence	Frequently occur simultaneously with esophageal varices because the two diseases share common risk factors	Frequently occurs simultaneously with PHG because the two diseases have common risk factors
Location	Stomach: Predominantly fundus and body	Distal esophagus: Also can have gastric varices or ectopic varices in other gastrointestinal regions, particularly duodenum
Diagnosis	Esophagogastroduodenoscopy	Esophagogastroduodenoscopy
Endoscopic appearance	Erythematous small polygonal areas of mucosa surrounded by a fine, whitish, reticular or mosaic/snakeskin mucosa with red or brown spots	Serpiginous mucosal greyish luminal projections in distal esophagus
Clinical presentation	Mild acute or chronic bleeding	Acute gastrointestinal bleeding-typically massive
Severity of bleeding	Typically mild and not life-threatening	Typically severe and life-threatening
Histology		Not biopsied at endoscopy
Endoscopic therapy	Limited role	Variceal ligation recommended as initial therapy. Sclerotherapy an alternative therapy
Medical therapy	Octreotide	Octreotide
	Propranolol	Propranolol
	Vasopressin or vasopressin analogues-infrequently recommended any more	Vasopressin or vasopressin analogues-infrequently recommended any more
Blakemore tube	Not recommended	Sometimes used for refractory bleeding especially as a temporizing measure before performing more definitive therapy
Angiographic therapy	TIPS used as a last resort	TIPS recommended if endoscopic therapy fails
Transfusion of packed erythrocytes	Transfuse only to hematocrit of about 28. Over-transfusion may increase portal pressure and induce greater bleeding	Transfuse only to hematocrit of about 28. Over-transfusion may increase portal pressure and induce greater bleeding
Liver transplantation	Improves or resolves with liver transplantation	Improves or resolves with liver transplantation
Prognosis	Rarely fatal	Frequently fatal

TIPS: Transjugular intrahepatic portosystemic shunt; PHG: Portal hypertensive gastropathy.

Table 11 Rates of gastrointestinal bleeding from portal hypertensive gastropathy

Ref.	Year published	Population	Bleeding from PHG	Transfusions required
McCormack et al[3]	1985	127 patients with portal hypertension of various etiologies	29 patients out of 65 with PHG, representing 25% of the total number of bleeds from all sources; 9 episodes presenting with bleeding; 71 episodes of subsequent bleeding	2-15 units required for 60 bleeds
D'Amico et al[25]	1990	212 patients with cirrhosis; 75 being treated with sclerotherapy
Sarin et al[8]	1992	107 patients with portal hypertension presenting with variceal bleeding, undergoing sclerotherapy	No bleeding before sclerotherapy from PHG (4/107 had PHG); 2/13 post-sclerotherapy patients who developed PHG	Average of 4 units per patient with range of 2-8 units
Pérez-Ayuso et al[103]	1991	54 cirrhotic patients with PHG, in a RCT to look for rebleeding; propranolol 26 vs control 28	First hemorrhage: Acute/chronic bleeding in propranolol group 12/14; in control 12/16, rebleeding: Acute/chronic; in propranolol 6/6; in control 10/12
Gostout et al[217]	1993	Patients admitted for GI bleeding (1496)	12 patients (0.8%), representing 8% of nonvariceal bleeding in patients with liver disease
Primignani et al[34]	2000	373 patients with cirrhosis; PHG in 299 patients (80.1%)	8 PHG patients with acute bleeding; chronic bleeding in 34 patients
Merli et al[37]	2004	222 cirrhotic patients with portal hypertension; 48 patients with PHG on enrollment	During follow up for 47 ± 28 (SD) mo, acute bleeding 9, chronic bleeding 7 from PHG
Kimura et al[218]	2014	297 patients with living donor liver transplantation; retrospective analysis	2 patients bled from PHG within 3 mo after transplantation

PHG: Portal hypertensive gastropathy; RCT: Randomized controlled trial; GI: Gastrointestinal.

Table 12 Treatment of acute or chronic gastrointestinal bleeding from portal hypertensive gastropathy

Acute bleeding

Patient stabilization

Treat severe coagulopathy with highly elevated INR associated with cirrhosis with fresh frozen plasma

Treat severe thrombocytopenia associated with hypersplenism and bone marrow suppression from alcoholism with platelet transfusions

Transfuse packed erythrocytes to main hemoglobin level at about 8 g/dL

Consider antibiotic prophylaxis in patient with cirrhosis

Endoscopic therapy from bleeding-rarely used

Consider argon plasma coagulation

Hemospray - an experimental therapy

Pharmacotherapy

Octreotide - first line therapy

Vasopressin or terlipressin - second line therapy

Proton pump inhibitor therapy - adjunct therapy

Propranolol - can be instituted after bleeding controlled and patient stabilized

Interventional therapy

TIPS - for uncontrolled hemorrhage or for bleeding from PHG associated with variceal bleeding

Liver transplantation - for advanced end stage liver disease

Chronic bleeding

Treatment of anemia

Transfusions of packed erythrocytes as necessary

Iron replacement therapy

Pharmacotherapy

Consider propranolol

TIPS: Transjugular intrahepatic portosystemic shunt; PHG: Portal hypertensive gastropathy; INR: International normalized ratio.