Gastric lesions in portal hypertension: inflammatory gastritis or congestive gastropathy?

Effect of hepatic collateral hemodynamics on gastric mucosal blood flow in patients with liver cirrhosis

The dependence of the gastric mucosal change in liver cirrhosis on the extrahepatic collaterals is still unknown. Therefore we studied the influence of these collateral hemodynamics on gastric mucosal blood flow and gastric mucosal lesions. The subjects were 23 cirrhotic patients and were divided into two groups by the findings of percutaneous transhepatic portography. The first group consisted of 14 cases whose extrahepatic collaterals were via esophageal varices (group I). The second group included 9 cases having collaterals other than esophageal varices (group II). Multiple red spots were observed in 13 of 14 cases in group I, and two of nine cases in group II. Gastric mucosal blood flow was 2.0 +/- 0.9 volts (mean +/- SD) in group I, 4.0 +/- 1.2 in group II. A statistically significant difference was observed between groups I and II. Gastric mucosal blood flow was not significantly correlated with portal venous pressure in group I. It is concluded that, in liver cirrhosis, gastric mucosal blood flow is changeable according to the types of the extrahepatic collaterals.

Gastromucosal lesions in rabbits with chronic schistosomiasis

Upper gastrointestinal hemorrhage is one of the most important complications in portal hypertension secondary to schistosomiasis. Esophageal varices and gastric mucosal lesions are additional sources of bleeding. We studied the histologic and ultrastructural features of gastric mucosa in rabbits with chronic schistosomiasis (n = 10), with normal animals (n = 10) as controls. Our results confirm that in schistosomiasis, the gastric mucosa has characteristic functional and morphological features that may predispose it to the various damaging factors. Mucosal specimens reveal dilated submucosal vein with submucosal edema, ectasia of mucosal capillaries and venules. The mucosal vessels have conspicuous endothelial cells with prominent cytoplasm and numerous tiny projections extending into the vessel lumen. The submucosal venules show morphologic feature of arterialization. There are increased submucosal arteriovenous communications with a reduction in the effective mucosal blood flow. In addition, there are a number of eggs seen in the gastric mucosa of the rabbits with schistosomiasis. The granuloma may cause structural damage to the gastric mucosa. This finding suggests that schistosomiasis may play an important role in gastric lesions.

Effects of endoscopic injection sclerotherapy on portal hypertensive gastropathy: a prospective study

The effect of endoscopic injection sclerotherapy (EIS) for esophageal varices on portal hypertensive gastropathy (PHG) was investigated in 137 patients who underwent EIS from July 1987 to March 1990. Two groups, PHG(+) (N = 35) and PHG(-) (N = 102) were distinguished by endoscopic findings obtained before EIS. PHG was classified into four grades by endoscopy scored as 0, 1, 2, or 3. The PHG score significantly worsened after EIS (p < 0.01), and PHG became worse 6 to 9 months after the eradication of varices followed by gradual improvement. Recurrent small veins, which required additional EIS, appeared more frequently in the PHG(+) group (p < 0.05). New gastric varices appeared or gastric varices enlarged after EIS more frequently in the PHG(+) group (7 patients, 20.0%) than in the PHG(-) group (12 patients, 11.8%), but this was not statistically significant. Thus, frequent endoscopy after EIS is needed with special attention directed to development of PHG and gastric varices, especially for patients with PHG prior to treatment.

Management of gastric varices

Gastric varices (GV) are a common (20%) accompaniment of portal hypertension; they are more often seen in those patients who bleed than in those who do not (27% versus 4%, p < 0.01). They can develop in both segmental and generalized portal hypertension. Depending on their location and relation with oesophageal varices, GVs can be classified as gastrooesophageal varices (GOV) and isolated gastric varices (IGV); each of these can be further subdivided as follows: GOV1 (extension of oesophageal varices along lesser curve) and GOV2 (extension of oesophageal varices towards fundus); and IGV1 (varices in the fundus) and IGV2 (isolated varices anywhere in the stomach). The common presentation of GVs is variceal bleeding and encephalopathy. In comparison with oesophageal varices, GVs bleed significantly less often (64% versus 25%, p < 0.01) but more severely (2.9 +/- 0.3 versus 4.8 +/- 0.6 transfusion units, p < 0.01). Patients with GOV2 and IGV1 bleed more often than patients with other types of GVs. Sclerotherapy for oesophageal varices can significantly influence the natural history of GVs. GOV1, or lesser curve varices, disappear in the majority of cases (59%) after obliteration of oesophageal varices. In those with persisting GOV1, the incidence of bleeding and mortality is high and these patients require gastric variceal sclerotherapy (GVS). During oesophageal variceal sclerotherapy, bleeding can occasionally be induced from GVs. After obliteration of oesophageal varices, recurrence as GVs (secondary GVs) can occur in about 9% of patients. Emergency GVS is quite effective in controlling acute bleeding from GVs, more so than balloon tamponade. Potent sclerosants like tetradecyl sulphate and alcohol and a glue, bucrylate, have been quite effective. Elective GVS can achieve obliteration of GVs in nearly 70% of patients. Rebleeding and ulceration are common complications of GVS; probably related to incomplete obliteration and mucosal injury respectively. Splenectomy is quite effective in treating GVs due to segmental protal hypertension. For GV bleeding due to generalized portal hypertension, a shunt operation is often effective. TIPS procedure appear to be a very promising therapy for GV bleeding. Liver transplantation may be a superior alternative to sclerotherapy and shunt surgery for gastric varices.

Portal hypertensive gastropathy

There is now substantial clinical evidence to suggest that portal hypertensive gastropathy is an important source of gastrointestinal bleeding in patients with portal hypertension. Although a relatively uncommon presenting feature in such patients, it appears to become progressively more frequent and important the longer such patients with bleeding oesophageal varices survive after treatment by endoscopic sclerotherapy. It is now being increasingly recognized as the most important cause of haemorrhage after oesophageal varices in such patients. The endoscopic and histological characteristics of the condition are now well established but from a clinical point of view it is important to distinguish it from a number of other disorders. The pathogenesis of portal hypertensive gastropathy is poorly understood; venous congestion secondary to portal hypertension undoubtedly plays an important role but this is not thought to account entirely for the condition since abnormalities in the arterial blood supply are also observed. Many abnormalities in gastric mucosal function have been reported but it is unclear whether these are secondary disturbances or whether they play an important primary role in the development of the condition. Animal studies to date have not been helpful due to the lack of a satisfactory experimental model. Portocaval shunt surgery cures portal hypertensive gastropathy but propranolol has been shown to be highly effective in controlling haemorrhage from this condition and should now be considered the treatment of choice. The mechanism of action is unclear, and it remains to be shown whether other beta-blockers, or indeed any other drugs, are useful in treating this disorder.

Characterization of spontaneous and ethanol-induced gastric damage in cirrhotic rats

Cirrhosis was induced in Sprague-Dawley rats via ligation of the common bile duct. Changes in gastric blood flow and mucosal architecture were examined. Using an ex vivo gastric chamber preparation, the susceptibility of the cirrhotic gastric mucosa to injury by 20% ethanol was also examined. The gastric mucosa of cirrhotic animals was abnormal, even before ethanol administration. The macroscopically visible damage in these animals ranged from superficial hyperemia to epithelial sloughing. These gastric lesions were similar in appearance to the gastropathy described in cirrhotic patients, including "cherry-red spots" and areas of generalized erythema. Cirrhotic rats had a lower resting gastric transmucosal potential difference than control rats, and their gastric mucosa was also significantly more susceptible to damage by topical ethanol application. Ethanol administration caused a significant increase in gastric blood flow in control rats, whereas it significantly decreased gastric blood flow in cirrhotic rats. This lack of a reactive hyperemic response in cirrhotic rats may be responsible for the increased susceptibility of the gastric mucosa to ethanol-induced damage.

Sequence of morphological and hemodynamic changes of gastric microvessels in portal hypertension

Changes in gastric microvasculature and blood flow at different phases of portal hypertension were studied in rats 1, 2, 3, 4, and 15 days after induction of portal hypertension or sham operation. Vessel lumen and vessel wall thickness were expressed as a ratio referred to the vessel size. On day 2 after constriction of the portal vein, gastric blood flow was decreased (0.57 +/- 0.06 vs. 0.99 +/- 0.20 mL.min-1.100 g-1; P less than 0.05), and gastric vessels had a distended lumen (0.42 +/- 0.02 vs. 0.28 +/- 0.03; P less than 0.01) and a thin wall (2.11 +/- 0.2 vs. 3.82 +/- 0.4; P less than 0.01). On day 4, the gastric blood flow of portal hypertensive animals was increased (1.15 +/- 0.14 vs. 0.71 +/- 0.07 mL.min-1.100 g-1; P less than 0.05), whereas gastric vessels had a reduced lumen (0.27 +/- 0.02 vs. 0.33 +/- 0.02; P less than 0.01) and a thick wall (4.19 +/- 0.52 vs. 3.16 +/- 0.30; P less than 0.05). By day 15, vessels with the largest lumens (0.45 +/- 0.01 vs. 0.29 +/- 0.01; P less than 0.01) and the thinnest walls (1.78 +/- 0.26 vs. 3.58 +/- 0.62; P less than 0.01) were observed in portal hypertensive animals. In conclusion, the gastric vessels of the 15-day portal vein-ligated rat resemble the structural abnormalities described in human portal hypertensive gastropathy.

Portal hypertensive gastropathy in patients with cirrhosis

Portal hypertensive gastropathy is a recently recognized important complication of cirrhosis. In the present study, the clinical features, portohepatic hemodynamics, and hepatic function were investigated in a series of 47 patients with cirrhosis. Mild gastropathy was found in 15 patients (32%) and severe gastropathy in 17 patients (36%). The presence of gastropathy seemed to be independent of age, sex, cause of cirrhosis, or grade of gastroesophageal varices. However, severe gastropathy was associated with an increase in portal venous pressure gradient (vs. control, P less than 0.01; vs. mild gastropathy, P less than 0.01), an increase in hepatic sinusoidal resistance (vs. control, P less than 0.01; vs. mild gastropathy, NS), and a decrease in hepatic blood flow (vs. control, P less than 0.01; vs. mild gastropathy, NS). In addition, patients with severe gastropathy had impaired metabolic activity of the liver, which was assessed by intrinsic clearance of indocyanine green (vs. control, P less than 0.01; vs. mild gastropathy, NS). These observations may have important therapeutic implications in patients with cirrhosis and portal hypertensive gastropathy.

Gastric compliance and motility in the portal hypertensive rat

In an ex vivo rat model, we compared the intraluminal pressure response of both the whole stomach and the antrum to progressive intraluminal distension in portal hypertensive and sham-operated rats. In both groups, this response featured a biphasic change in tone with superimposed phasic pressure waves. While the tonic pressure response to distension (reflecting gastric compliance) was similar in both groups, the frequency and amplitude of antral phasic pressure waves (reflecting antral motility) were greater in the portal hypertensive animals. These studies indicate that portal hypertension does not alter gastric compliance but is associated with an exaggerated antral motor response to distension, suggesting that this latter mechanism, rather than impaired accommodation, may explain the accelerated gastric emptying described previously in the portal hypertensive rat.

Factors influencing development of portal hypertensive gastropathy in patients with portal hypertension

Portal hypertensive gastropathy (PGP) is an important cause of bleeding in portal hypertension patients. Although hyperdynamic congestion seems to be the underlying mechanism, the factors that influence the development of PGP are not understood. To investigate these, 107 patients [cirrhosis, 35; noncirrhotic portal fibrosis (NCPF), 24; extrahepatic portal vein obstruction (EHPVO), 46; Budd-Chiari syndrome, 2] were prospectively studied. Eighty-three patients had Child's A, 17 had Child's B, and 7 had Child's C liver disease. Before sclerotherapy, although intravariceal pressure was similar, 4 cirrhosis patients (3.7%) but no NCPF or EHPVO patients had PGP. After sclerotherapy, 21 additional patients (20.3%) developed PGP during a follow-up of 23.2 +/- 3.4 months (range, 1-52). The incidence of PGP was higher in cirrhotic patients (37.1%) than in NCPF (16.7%; P less than 0.05) or EHPVO (8.7%; P less than 0.01) patients. The probability of developing PGP among all patients at the end of 52 months of follow-up was 30%, more in cirrhosis than in EHPVO (55% vs. 15%; P less than 0.005). Only 2 patients bled from PGP during follow-up. Development of PGP correlated with severity of liver disease, being more common in Child's C than Child's A patients (87% vs. 13%; P less than 0.001). PGP was seen more often in patients with gastroesophageal varices than in patients with esophageal varices alone (42% vs. 11%; P less than 0.01). In conclusion, the results show that development of PGP is significantly influenced by sclerotherapy, severity of liver disease, etiology of portal hypertension, coexisting gastric varices and is not directly correlated with intravariceal pressure.

Taurocholate induced gastric mucosal injuries in experimental portal hypertension

The susceptibility of the gastric mucosa to injury by topical sodium taurocholate (40 mmol/l) in hydrochloric acid (150 mmol/l) was studied in prehepatic and cirrhotic rat models of portal hypertension. Portal venous pressure was increased in rats who had undergone partial portal vein ligation compared with rats that had undergone sham operation on days 3, 7, and 28 after operation (20.6 (0.9), 14.8 (0.8), and 11.3 (0.5) mm Hg v 7.3 (0.7), 7.3 (0.6), and 8.2 (0.2) mmHg respectively (mean (SEM)). At day 3 gastric mucosal injuries were increased in rats with partial portal vein ligation compared with sham operated rats (55.3 (9.4) vs 22.3 (10.5) mm2, p = 0.006), but at the later time intervals there was no significant difference in injuries between the two groups. In rats with carbon tetrachloride induced hepatic cirrhosis, portal pressure was increased (15.6 (1.0) v 6.7 (0.6) mmHg), but again there was no significant difference in mucosal injuries relative to control animals. We conclude that gastric mucosal defence mechanisms are impaired in acute but not chronic experimental portal hypertension.

Portal hypertensive colopathy. A new entity

The aim of this paper was, first, to show in a case control study that in alcoholic cirrhotic patients colonic vascular ectasias (VE) are a complication of portal hypertension and, second, to establish in a histomorphometric study that colonic vascular ectasias and rectal varices (RV) are only endoscopic features of a new entity: portal hypertensive colopathy, the pathologic basis of which is colonic mucosal capillary ectasia. In the case control study, for each case, three age- and sex-matched controls selected from consecutive patients were used. Sixteen alcoholic cirrhotic patients, 12 men, 4 women (mean age +/- SD: 62 +/- 10 years) had colonic vascular ectasias. The prevalence of esophageal varices (88% vs 44%, P less than 0.005), esophageal varices (greater than or equal to 5 mm) (44% vs 12.5%, P less than 0.01), previous history of bleeding from esophageal varices (44% vs 8%, P less than 0.005), and rectal varices (63% vs 6%, P less than 0.001) was significantly greater in cases with colonic vascular ectasias than in controls without colonic vascular ectasias. The relative risk of colonic vascular ectasias in alcoholic cirrhotic patients with esophageal varices versus cirrhotic patients without esophageal varices was 14.4 (95% confidence interval 2.8-75.3). In the histomorphometric study, cirrhotic patients with vascular ectasias and/or rectal varices had a significantly higher mean diameter of vessels (20.3 +/- 1.5 microns vs 18.7 +/- 1.6 microns, P less than 0.05) and a higher mean cross-sectional vascular area (2143 +/- 396 microns 2 vs 1676 +/- 345 microns 2, P less than 0.05) than cirrhotic patients without vascular ectasias and/or rectal varices.(ABSTRACT TRUNCATED AT 250 WORDS)

Portal colopathy: prospective study of colonoscopy in patients with portal hypertension

Twenty patients with portal hypertension related to a variety of causes prospectively underwent colonoscopy for hematochezia (n = 10), hemoccult positive stool and anemia (n = 9), or polyp found with screening flexible sigmoidoscopy (n = 2) (includes 1 patient with anemia/heme-positive stool). Twelve patients (60%) had previously undergone a course of sclerotherapy, and 10 (50%) had endoscopic evidence of congestive gastropathy. Colonoscopic findings included mucosal abnormalities resembling multiple vascular ectasias in 14 (70%), 4 of whom also had endoscopic features suggesting a mild, chronic colitis. Neither signs of chronic liver disease nor stigmata suggestive of more severe portal hypertension correlated with the colonoscopic findings. Two patients required heater probe therapy for actively oozing lesions resembling vascular ectasias and an additional two patients sclerotherapy for bleeding midrectal varices. Although likely an overestimate of the frequency, this study suggests that portal colopathy can occur in portal hypertension. Vascular ectasialike lesions in such settings may be associated with acute as well as chronic gastrointestinal bleeding and may require pharmacological, directed endoscopic, or portal decompressive therapy. Additional studies are required to determine not only the pathophysiology but also the true frequency of this entity.

The stomach in liver cirrhosis. Endoscopic, morphological, and clinical correlations

The stomachs of cirrhotic patients are frequently subject to a number of alterations, detectable by endoscopy, the presence of which indicates a disturbance in the mucosa. Several investigators believe that portal hypertension plays an etiopathogenetic role. Three groups of subjects were studied prospectively: 83 cirrhotic patients with portal hypertension, 53 cirrhotic patients without portal hypertension, and 135 control subjects. Snake skin, scarlatina rash, and petechia were the most frequent endoscopic findings in the cirrhotic patients with portal hypertension (P less than 0.001); these findings were also most frequently present in association with each other in this group. There was no correlation between the endoscopic findings, the clinical gravity of liver cirrhosis (Child-Pugh grade), and the gravity of esophageal varices (Beppu score). There were no characteristic inflammatory findings in the gastric mucosa. Hypergastrinemia was often observed in cirrhotic patients with and without angiodysplasias.

Structural and functional changes of the gastric mucosa in rats with portal hypertension

Structural and functional changes of the gastric mucosa were studied in rats made portal hypertensive by partially ligating the portal vein. Studies were carried out at either 3 or 12 days after ligation or sham operation. At 3 days, structural changes were greater than at 12 days, the major effects being vascular congestion in the lamina propria, muscularis mucosa, submucosa, and submucosal oedema. Transmission electron microscopy showed only a mild hyperplasia in the muscularis mucosa. Gastric blood flow appeared to decrease at 3 days post-ligation compared to sham-operated control rats, but was significantly increased by 12 days after ligation (P less than 0.01). Cardiac output also appeared to increase in the portal hypertensive rats by 12 days post-ligation but this was not statistically significant. Portal venous inflow was significantly increased by 12 days (P less than 0.05) but after correction for collateral circulation liver blood flow had returned to normal values by 12 days post-ligation.

Propranolol in prevention of recurrent bleeding from severe portal hypertensive gastropathy in cirrhosis

The two main causes of gastrointestinal bleeding in cirrhosis are oesophageal varices and portal hypertensive gastropathy (PHG). Rebleeding from varices can be prevented by beta-blockers, but it is not clear whether these drugs effectively reduce rebleeding from PHG. 54 cirrhotic patients with acute or chronic bleeding from severe PHG took part in a randomised, controlled trial to investigate the efficacy of propranolol in prevention of rebleeding from PHG. 26 patients were randomised to receive propranolol daily at a dose that reduced the resting heart rate by 25% or to 55 bpm (20-160 mg twice daily), throughout mean follow-up of 21 (SD 11) months. 28 untreated controls were followed-up, with the same examinations, for 18 (13) months. The actuarial percentages of patients free of rebleeding from PHG were significantly higher in the propranolol-treated patients than in the untreated controls at 12 months (65% vs 38%; p less than 0.05) and at 30 months of follow-up (52% vs 7%; p less than 0.05). Propranolol-treated patients had fewer episodes of acute bleeding than controls (0.010 [0.004] vs 0.120 [0.040] per patient per month). Multivariate analysis showed that absence of propranolol treatment was the only predictive variable for rebleeding. Actuarial survival was slightly higher in the propranolol group than in the controls, but the difference was not significant. Thus, long-term propranolol treatment significantly reduces the frequency of rebleeding from severe PHG, and may improve the prognosis of cirrhotic patients with this disorder.

Jejunal permeability to water and electrolytes in patients with chronic intrahepatic hypertension: evidence for a role of aldosterone

Acute prehepatic portal hypertension induces intestinal secretion in animal models. In the course of chronic liver disease, however, these changes are not observed, despite higher portal pressures than those found in experimental studies. Eight patients without diarrhoea and with chronic alcoholic liver disease were examined for evidence of increased jejunal secretion; their suprahepatic wedge pressure was raised from 21 to 45 mmHg (mean 34.6 mmHg). Jejunal perfusion with a triple lumen catheter and a proximal occluding balloon was used to study net flows of water and chloride as well as net and unidirectional flows of sodium and potassium. No statistical difference in intestinal flows of water and electrolytes was noted between cirrhotic patients and control subjects after infusion with a 30 mmol/l glucose solution. Infusion with a 30 mmol/l mannitol solution resulted in a lower absorption of water, Na, K, and Cl than with the glucose solution. A higher rate of Na secretion was observed in cirrhotic patients than control subjects after infusion with 30 mmol/l mannitol (p less than 0.01). In addition, the rate of Na secretion was higher in cirrhotic patients than in control subjects (p less than 0.05). There was no correlation between the net flow of Na and the suprahepatic wedge pressure. A second perfusion with a 30 mmol/l glucose solution was given 75 minutes after a bolus injection of spironolactone (400 mg). Net flows of Na and Cl were lower in cirrhotic patients than in control subjects (p less than 0.05) because of a lower absorption of Na. Patients with gradually developing portal hypertension have moderate jejunal secretions of H2O and electrolytes which we assume are partly masked by increased absorption resulting from hyperaldosteronism. In contrast to animal models, this mechanism may be part of the jejunal adaptation to permeability in acute portal hypertension.

Congestive gastropathy and Helicobacter pylori: an endoscopic and morphometric study

Congestive gastropathy is a frequent cause of upper gastrointestinal haemorrhage in patients with portal hypertension. The pathogenesis is thought to involve venous congestion with gastric mucosal capillary dilatation. We studied the relation between gastric mucosal capillary dilatation, measured morphometrically, and endoscopic appearances in 74 patients with portal hypertension and 20 control subjects. We also investigated the frequency of gastric colonisation with Helicobacter pylori. Mucosal capillaries in patients were significantly dilated compared with control subjects (p less than 0.001) but the degree of dilatation was not related to the severity of the endoscopic appearances. H pylori was identified in 19 of 74 (26%) patients but was not related to the severity of the endoscopic appearances. These results suggest that other factors in addition to mucosal venous and capillary congestion are important in the pathogenesis of endoscopic congestive gastropathy and that gastric colonisation with H pylori is unlikely to be one of these factors.

Snake skin pattern gastropathy in cirrhotic patients

Gastric mucosal lesions are common in patients with cirrhosis. Among them, snake skin pattern gastropathy (SSPG) is the most distinguishing one. A prospective study was conducted to investigate the incidence of SSPG in cirrhotic patients, the relationship between the degree of portal pressure and SSPG, and the possible association of SSPG with serum levels of gastrin and pepsinogen I. SSPG was found to be significantly more common in 100 cirrhotic patients than in 100 age- and sex-matched healthy controls (41% vs 0%, P less than 0.0001). Hepatic venous pressure gradient and serum gastrin and pepsinogen I levels were measured in 21 cirrhotic patients with SSPG and 25 cirrhotics without SSPG. There was no significant difference in hepatic venous pressure gradient (16.1 +/- 4.4 mmHg vs 16.1 +/- 4.9 mmHg, P greater than 0.05), serum gastrin level (78.0 +/- 26.7 pg/mL vs 80.1 +/- 32.5 pg/mL, P greater than 0.05) and serum pepsinogen I level (69.5 +/- 26.6 ng/mL vs 65.2 +/- 26.1 ng/mL, P greater than 0.05) in cirrhotic patients with or without SSPG. In conclusion, SSPG is common in cirrhotic patients. Portal pressure per se may not be the only factor causing SSPG--other aggressive factors may be needed together to cause the gastropathy. There is no evidence of correlation between serum gastrin or pepsinogen I level and SSPG.

Gallbladder wall thickening (congestive cholecystopathy) in chronic liver disease: a sign of portal hypertension

A thickened gallbladder wall is often seen with ultrasound in alcoholic cirrhosis. Hypoalbuminaemia is thought to be the cause since there is a strong association between bowel wall thickening and low serum albumin. To determine the role of portal hypertension in producing gallbladder wall thickening we studied 40 consecutive stable patients-37 with cirrhosis and three with portal hypertension due to primary biliary cirrhosis. Ultrasound assessment of the gallbladder wall was made after an overnight fast using a Technicare autosector. Wall thickness 4 mm or greater was considered abnormal. Twenty-seven patients had a thickened gallbladder wall and all had evidence of portal hypertension. Hypoalbuminaemia was not an important factor since it was only present in six cases with thickened walls. In two cases reduction in portal pressure with oral propranolol was associated with a decrease in gallbladder wall thickness. These results suggest that portal hypertension, not hypoalbuminaemia, is the dominant factor causing gallbladder wall thickening in cirrhosis. Ultrasound demonstration of gallbladder wall thickening in chronic liver disease should suggest the presence of portal hypertension.

Gastric red spots in patients with cirrhosis: subclinical condition of gastric mucosal hemorrhage?

The present study was intended to assess the incidence and the nature of gastric red spots (GRS) in patients with liver cirrhosis. Endoscopically, GRS was more frequently observed in patients with cirrhosis (n = 146) than those without cirrhosis (n = 103) (43.2% vs. 4.8%; P less than 0.001). There was no relationship between the incidence of GRS and the severity of cirrhosis or the size of varices. Portal venous pressure was higher in cirrhotics with GRS (n = 21) than those without GRS (n = 25) (33.7 +/- 6.0 mmHg vs. 28.2 +/- 4.8 mmHg; P less than 0.001). Morphometric analysis using the biopsied specimens was made in 16 cirrhotics with GRS, 12 cirrhotics without GRS, and 15 non-cirrhotics. The capillary bed occupation ratio (vascular area/mucosal area) was higher in cirrhotics with GRS (9.3 +/- 4.0%) than those without GRS 84.1 +/- 1.1%) or the non-cirrhotics (3.4 +/- 9.8%) (P less than 0.005, P less than 0.005), while there was no significant differences in the number of capillaries per unit area. Infiltrating inflammatory cell count was similar among the three groups. Extravascular red blood cell count per unit area was higher in cirrhotics with GRS (29.7 +/- 31.4) than those without GRS (5.4 +/- 5.1) or non-cirrhotics (5.4 +/- 6.3) (P less than 0.05, P less than 0.01). Furthermore, extravasation of red blood cells through defective portion of the endothelium and interposition of red blood cells in interepithelial spaces were observed electron microscopically in cirrhotics with GRS.(ABSTRACT TRUNCATED AT 250 WORDS)

Natural history of congestive gastropathy in cirrhosis. The Liver Study Group of V. Cervello Hospital

In a prospective study of the natural history of congestive gastropathy, 212 consecutive cirrhotic patients (75 treated with sclerotherapy) were included. Mean follow-up was 46 months. Mild gastropathy (mosaiclike pattern) was found in 110 patients and severe gastropathy (granular mucosa with cherry spots) was found in 20. Prevalence of Helicobacter pylori, formerly Campylobacter pylori, was 50% in patients without, 43% in those with mild, and 28% in those with severe gastropathy. Congestive gastropathy was significantly more frequent in patients treated with sclerotherapy (83% vs. 50%, P less than 10(-5)). Sixty-month actuarial proportions of patients free of anemia (in the absence of hematemesis or melena), were 17% with severe, 62% with mild, and 93% without gastropathy (P less than 10(-8]. Corresponding figures for overt bleeding were 25%, 73%, and 87% (P less than 10(-7], whereas those for survival were 46%, 72%, and 85% (P = 0.0005), respectively. A multivariate regression analysis supported the following conclusions: (a) sclerotherapy and the presence of large esophageal varices significantly increase the risk of congestive gastropathy, which (b) is a significant risk indicator of both chronic and overt bleeding but does not independently affect survival.

Incidence of large oesophageal varices in patients with cirrhosis: application to prophylaxis of first bleeding

Because several studies have suggested that beta blockers are effective in the prophylaxis of first variceal bleeding in cirrhosis, screening for oesophageal varices might be appropriate. We prospectively studied 84 cirrhotic patients without obvious evidence of large oesophageal varices and previous bleeding during a mean follow up of 16 months. At entry to the study 41 patients had no oesophageal varices and in 43 these were grade 1. The subsequent percentages of patients without large oesophageal varices were 74% at one year and 52% at two years. Univariate analysis showed that a longer duration of cirrhosis (p less than 0.05) and grade 1 oesophageal varices at entry (p less than 0.001) were predictive factors for the occurrence of large oesophageal varices, whereas, multivariate analysis showed that the initial size of the oesophageal varices (p less than 0.001), a high initial Child-Pugh score, and a smaller improvement in Child-Pugh score during the study were independent risk factors. Among patients with grades 0 and 1 oesophageal varices at the start of the study the proportions with large oesophageal varices at two years were 31% and 70% respectively. We have calculated that, accepting a maximum risk of first bleeding of 10% without prophylactic treatment, a patient without oesophageal varices should be screened endoscopically every other year, while a patient with grade 1 disease should benefit from one annual upper gastrointestinal endoscopy.

Endoscopic and histologic appearance of the gastric mucosa in patients with portal hypertension

To assess reliability of the endoscopic and histologic appearance of the gastric mucosa for diagnosing portal hypertension, 50 patients with portal hypertension and 1323 controls were studied. Endoscopic evidence of mild gastritis was seen more frequently in patients with portal hypertension than in the control group (42% vs. 13.1%, p less than 0.001). The mosaic sign was also seen more frequently in patients with portal hypertension compared with controls (14% vs. 0.9%, p less than 0.001). However, the mosaic sign was found to be nonspecific, and the sensitivity for diagnosis of portal hypertension was only 14%. Biopsy specimens from the stomach of all patients with portal hypertension and 100 controls with a normal endoscopic appearance revealed mucosal vascular congestion in 72% of patients with portal hypertension compared with 59% of controls (NS). There was no correlation between endoscopic and histologic evidence of congestive gastropathy. Similarly, there was no correlation between the severity of mucosal vascular congestion and the degree of inflammatory changes observed in the biopsy specimens; both in the control (r = 0.1) and in patients with portal hypertension (r = 0.14). It is concluded that endoscopic and histologic features of the gastric mucosa in patients with portal hypertension are of low sensitivity and nonspecific and cannot be used to diagnose portal hypertension.

The 'mosaic-like' pattern of portal hypertensive gastric mucosa after variceal eradication by sclerotherapy

The 'mosaic-like' pattern of portal hypertensive gastric mucosa has been evaluated endoscopically in 38 patients referred for elective sclerotherapy, before the first session, after the complete eradication of varices and six months later. Of 38 patients studied, 18 patients exhibited mild, and 20 patients exhibited negative, findings of congestive gastropathy prior to sclerotherapy. Seventeen and 18 patients, respectively, developed aggravated changes of congestive gastropathy after the completion of sclerotherapy (P = 0.003). We consider that obliteration of varices by means of endoscopic sclerotherapy influences the development of gastric congestion changes in the majority of patients. However, further studies are required to relate the direction of blood flow in the portal system as well as the level of portal pressure with the congestive gastropathy findings in such patients.

Effects of propranolol on gastric microcirculation and acid secretion in portal hypertensive rats

Rats with chronic portal hypertension have an increased gastric mucosal blood flow and an impaired acid secretory response to pentagastrin stimulation. This study investigated the effects of propranolol, a drug widely used in the treatment of portal hypertension, on gastric mucosal blood flow and acid secretion in portal hypertensive rats with partial portal vein occlusion. In study I, gastric mucosal blood flow, measured by hydrogen gas clearance, and acid output were determined in basal conditions and after the administration of propranolol (0.3 mg/kg/min) or vehicle infusion in portal hypertensive and sham-operated rats. Gastric mucosal blood flow was significantly higher (p less than 0.005) in portal hypertensive rats than in sham-operated rats, and it was significantly reduced (p less than 0.05) after propranolol infusion in portal hypertensive rats (39 +/- 2 vs. 35 +/- 3 ml/min/100 gm). Basal acid output was not significantly modified with propranolol infusion, either in portal hypertensive or sham-operated animals. In study II, acid output was measured in portal hypertensive rats in basal conditions, during pentagastrin (20 micrograms/kg/hr) infusion and after the combined infusion of pentagastrin and propranolol (or vehicle). Pentagastrin infusion significantly increased (p less than 0.001) acid output, but propranolol did not modify stimulated gastric acid secretion. In conclusion, propranolol induced a slight but significant reduction in gastric mucosal blood flow and did not change basal or stimulated gastric acid secretion.

Gastric mucosal prostaglandin E2 levels in cirrhosis and portal hypertension

Prostaglandin E2 (PGE2) tissue levels were measured, using radioimmunoassay, in specimens from the gastric antral mucosa in (a) healthy subjects, (b) patients without liver diseases in the absence or presence of gastric ulcers, and (c) patients with alcoholic cirrhosis in the absence or presence of gastric ulcers. These groups were divided further into subgroups with or without portal hypertension. PGE2 tissue levels in subjects without liver diseases were not significantly different from those of cirrhotic patients without portal hypertension. However, in cirrhotic patients with portal hypertension, the PGE2 content was significantly lower, especially in the presence of congestion in the mucosa (about 70-80%). When a gastric antral ulcer was present, a further statistically significant decrease of the PGE2 levels was observed. It was concluded that a decrease in the PGE2 tissue levels in the gastric mucosa of cirrhotic patients is related to the presence of portal hypertension. Congestion in the mucosa, as a pathogenetically relevant factor for mucosal PGE2 deficiency, may play a role.

Esophageal varices

Bleeding from esophageal varices is related to the size and pressure of varices, endoscopic danger signs, and severity of liver failure. Prevention of bleeding with propranolol has given conflicting results in controlled trials, but is a safe treatment. Prophylactic sclerotherapy has been shown to reduce bleeding in European studies, but this has not been confirmed by studies in the United States. Acute variceal bleeding can usually be controlled by sclerotherapy, which may be supplemented by pharmacotherapy with vasopressin, nitroglycerin, or somatostatin. Recurrent bleeding is prevented initially by sclerotherapy, with surgery reserved for patients who have not responded to this treatment. Once bleeding has been controlled, the suitability and timing of hepatic transplantation must be considered.

Effect of portal hypertension on in vivo bile acid-mediated small intestinal mucosal injury in the rat

This study's purpose was to determine whether portal hypertension adversely affects small intestinal mucosal injury. Portal hypertension was produced in male Sprague-Dawley rats by two-stage ligation of the portal vein. Sham-operated rats were used as controls. Two weeks later, intestinal injury was produced by in vivo perfusion with 5 mM chenodeoxycholic acid for 30 min. Intestinal injury was assessed by quantitative morphometry and by measuring intestinal water and mannitol absorption. Portal hypertension resulted in more injury in the distal perfused intestine as manifested by increased villus tip denudation [portal hypertensive 52.5 +/- 9.6 (SEM) vs controls 28.1 +/- 5.7 microns, P = 0.05). Additionally there was a significant decrease in the unperfused duodenal villus height in portal hypertensive rats (portal hypertensive 755 +/- 22 vs controls 848 +/- 28 microns, P less than 0.02). Portal hypertension had no significant effect on the increase in mannitol absorption or water secretion caused by chenodeoxycholic acid perfusion. This study suggests that portal hypertension alters small intestinal mucosa and increases susceptibility to injury.

Prevalence of endoscopic findings in 510 consecutive individuals with cirrhosis evaluated prospectively

Upper gastrointestinal hemorrhage is one of the more important complications of cirrhosis and a major cause of death in such patients. The main sites of bleeding are esophageal varices, gastritis, and peptic ulcers. In order to determine the prevalence of either potential bleeding lesions or of other endoscopic findings in hemodynamically stable individuals with various etiologies of cirrhosis, 510 consecutive cirrhotic patients, evaluated for possible orthotopic liver transplantation (OLTx) underwent an upper gastrointestinal endoscopy for combined diagnostic and therapeutic purposes. The patients were divided into two main groups: 319 patients with parenchymal liver disease and 191 patients with cholestatic liver disease. Gastritis was found significantly more often in patients with parenchymal liver disease than in those with cholestatic liver disease (49.8% vs 30.9%; P less than 0.001). In contrast, the prevalence of esophagitis, esophageal and gastric varices, gastric ulcer, duodenal ulcer, and duodenitis was similar in both groups. Normal endoscopic findings were present in 5.0% of the parenchymal group and 11.5% of the cholestatic group (P less than 0.02). Ascites and encephalopathy were found significantly more often in subjects with parenchymal liver disease as compared to those with cholestatic liver disease. Portal hypertension and its degree, as assessed by the presence and size of esophageal varices, was similar in both groups, and in both groups there was a statistically significant qualitative trend of increasing prevalence of esophageal varices with increasing severity of disease as estimated using Pugh-Child's criteria.

Gastric emptying of liquids and solids in the portal hypertensive rat

The effects of portal hypertension on gastric motor function were investigated using the rat staged portal vein ligation model. Gastric emptying of liquids and solids was studied separately following meals labeled with 51Cr or 99Tc by whole stomach scintillation counting. Portal hypertension was consistently established in experimental rats (splenic pulp pressure: mean +/- SEM, portal hypertension versus control, 16.8 +/- 0.7 vs 11.8 +/- 0.7 mm Hg, P less than 0.0001). Although liquids were emptied in an exponential manner and solids in a linear fashion, gastric emptying of both meals was more rapid in the experimental rats. Ten minutes after the liquid meal, more than 50% of the meal had emptied from the stomachs of portal hypertensive rats while only one third of the meal had cleared in the control group (P less than 0.02). Gastric emptying of the solid meal was significantly accelerated in experimental rats at 60 and 120 min (percent meal remaining: portal hypertension versus control, 41.9 +/- 4.0 vs 55.4 +/- 3.5 and 21.5 +/- 4.9 vs 32.6 +/- 4.3, P less than 0.05). Stomachs of portal hypertensive animals were heavier (P less than 0.009) and histologic examination revealed submucosal edema. Thus, a possible mechanism of the disrupted gastric motor function in portal hypertension is decreased gastric wall compliance secondary to edema.

Endoscopic classification of gastric varices

Endoscopic observations of gastric varices in 124 patients were classified according to form, location, and color. Form was classified into three types: tortuous (F1), nodular (F2), and tumorous (F3). Location was classified into five types: anterior (La), posterior (Lp), lesser (Ll) and greater curvature (Lg) of the cardia, and fundic area (Lf). Color was white (Cw) or red (Cr). Glossy, thin-walled focal redness on the varix was defined as red color spot (RC spot). Stepwise logistic regression analysis for multivariate adjustments was performed for all of the endoscopic covariates, and four risk factors (La, Lg, F2, RC spot) that affect bleeding from gastric varices were independently identified. This classification should aid in assessing gastric varices observed by fiberoptic endoscopy and help design appropriate treatment.

Diagnosis and hemodynamic assessment of portal hypertension

Rational treatment of portal hypertensive complications requires a knowledge of the cause of portal hypertension and an assessment of the severity of liver disease. In the United States, chronic liver disease, usually due to alcohol, is the most common underlying cause. The history, physical examination, and laboratory analysis are usually sufficient to confirm the presence of underlying liver disease. If there is any question as to the etiology of portal hypertension, however, a more complete evaluation is required, whether the presenting complication is ascites, variceal bleeding, or hypersplenism. Usually, such an evaluation will require a liver biopsy, portal pressure measurement, and angiography. Occasionally, a noninvasive evaluation will be sufficient, but the value of these noninvasive parameters is still under investigation. Surgical mortality generally depends on the severity of the liver disease. Therefore, surgical intervention must be carefully considered in comparison to other therapeutic modalities depending on the patient's hepatic functional reserve. Secondary bacterial peritonitis due to perforation requires surgery regardless of the severity of the underlying liver disease.

Portal hypertension predisposes the gastric mucosa to hemorrhagic shock/reperfusion injury

We have previously demonstrated that the portal hypertensive (PHT) gastric mucosa has unique functional and morphologic features which predispose it to increased damage by noxious agents such as aspirin or alcohol. In this study we examine the PHT gastric mucosa following hemorrhagic shock and reperfusion. Portal hypertension was produced in 12 rats using staged portal vein occlusion, and seven animals (controls) underwent sham procedures. All rats received 2 ml 0.1 N HCl intragastrically. Shock was then induced by withdrawing blood to reduce systemic arterial pressures to approximately 30 mm Hg for 20 min. Blood was then reinfused and stomachs were excised 20 min later for gross and microscopic quantitation of injury. We found that gross damage to gastric glandular mucosa was more than doubled in PHT rats over sham-operated controls. In PHT gastric mucosa, deep histologic necrosis involved 22.5 +/- 3.8% of mucosal section lengths compared with 6.9 +/- 2.0% in control mucosa (P less than 0.005). Histologically, mucosal injury patterns were predominantly ischemic, with deep necrosis and disintegration of glands and microvessels, all prominently more extensive in PHT mucosa. We conclude that PHT gastric mucosa has significantly increased susceptibility to damage following hemorrhagic shock/reperfusion compared with portal normotensive mucosa. Since hemorrhagic shock is a frequent complication of portal hypertension, this study suggests clinical investigations of gastric mucosal function and pathophysiology in PHT patients following hemorrhage and resuscitation.

Prevalence of duodenal ulcer in cirrhotic males referred for liver transplantation. Does the etiology of cirrhosis make a difference?

The prevalence of symptomatic duodenal ulcer (DU) assessed primarily in alcoholic males with cirrhosis is estimated to be approximately fivefold increased compared to the normal population. Little information is available, however, as to the prevalence of DU in nonbleeding, nonalcoholic subjects with cirrhosis. In order to estimate the prevalence of DU in males with various types of cirrhosis and its relation to the degree of portal hypertension, 216 male cirrhotic patients (165 with parenchymal liver disease and 51 with cholestatic liver disease) being evaluated for liver transplantation at the University of Pittsburgh between January 1985 and June 1987 underwent pan-upper gastrointestinal endoscopy. The prevalence of DU in each group was 7.8%. However, among the various subgroups it was as follows: chronic active hepatitis due to HBV: 9.4%, alcoholic: 12.2%, cryptogenic: 3.5%, autoimmune chronic active hepatitis: 6.6%, primary sclerosing cholangitis (PSC): 9.5%. The reference data for this study consist of data reported in the literature obtained in 355 healthy asymptomatic male volunteers. The prevalence of DU in this group is significantly less than in the study group (2.2% vs 7.8%; P less than 0.005). While the estimated risk for a DU is increased 3.71-fold (95% CI: 8.74, 1.57; P less than 0.005) in cirrhotic males in general as compared to normal males, only the subgroups with CAH due to HBV, alcoholism, and PSC were found to have an increased estimated risk of DU (all at least P less than 0.01). No association between the prevalence of DU and degree of portal hypertension could be demonstrated in either group.

Management of gastric variceal haemorrhage

From March 1979 to April 1988 nine patients with hepatic cirrhosis have presented with acute variceal haemorrhage from gastric varices. Of six patients who underwent emergency laparotomy those with modified Child's grade C (n = 3) died within 30 days of surgery. Six patients have been followed for 2 years or longer. In the three patients who underwent under-running of gastric varices alone, two patients developed oesophageal varices at 3 and 14 months, respectively, and in the third patient gastric varices recurred 3 years after surgery. In the remaining three patients, additional left gastric vein ligation was not associated with recurrence of gastric varices or the development of oesophageal varices.

Endoscopic approach to patients with portal hypertension: a complex diagnosis. A retrospective study based on 10 years' experience

We analyzed the endoscopic findings in 788 patients with esophageal and gastric varices who underwent upper gastrointestinal endoscopy between 1 January 1979 and 31 December 1988. Of these, 154 patients (19.6%) had gastric varices associated in various patterns with esophageal varices. Congestive gastropathy, occurring with esophageal and gastric varices (43.4%), was the most frequent pathology detected in our patients. Esophagitis was present in 15.8% of patients, but did not correlate with variceal bleeding. Endoscopy performed at 1 day to 1 week post-hemorrhage in 313 patients accurately identified the source of bleeding in only 57.2% of patients. This figure increased to 98.2% when we performed the examination within the first 24 h of hemorrhage. In this group varices were the source of hemorrhage in 72.3% of patients while the hemorrhage came from other sources, such as erosive gastritis, duodenal and gastric ulcer in 27.6% of patients.

Thickened stomach--an ultrasound sign of portal hypertension

Congestive gastrophy occurs with portal hypertension and is associated with vascular changes including dilatation and tortuosity of the submucous veins. Transabdominal ultrasound measurements of the stomach were made to determine whether these changes resulted in increased thickness of the stomach in patients with established cirrhosis and portal hypertension. Mean thickness of the antrum and body was 22.15 mm (range 13-31 mm) and 22.2 mm (range 13-31 mm) respectively in patients with portal hypertension: in the control group measurements of the antrum and body were 13.8 mm (range 8-20 mm) and 14.05 mm (range 11-19 mm) respectively (P less than 0.01 for both antrum and body). A thickened stomach may indicate the presence of portal hypertension.

Combined upper and lower gastrointestinal endoscopy: a prospective study in alcoholic and nonalcoholic cirrhosis

Upper gastrointestinal hemorrhage is one of the more important complications of cirrhosis. Most of the available data regarding the prevalence of upper and lower gastrointestinal sites of bleeding in cirrhotic patients have been obtained in individuals with alcoholic cirrhosis evaluated in the course of an acute gastrointestinal bleeding episode. Few data exist, however, as to the prevalence of either potential bleeding sites or of normal endoscopic findings in hemodynamically stable individuals with cirrhosis of any etiology. Five hundred ten cirrhotic subjects, who were evaluated for possible liver transplantation (OLTx) between January 1985 and June 1987, were included in this study. Seventy-five had alcoholic cirrhosis and 435 had nonalcoholic cirrhosis of various etiologies. Of these 510 patients, 412 underwent combined upper and lower gastrointestinal endoscopy and 98 underwent upper gastrointestinal endoscopy alone. Gastritis, gastric and duodenal ulcer disease were found significantly (each at least p less than 0.025) more often in patients with alcoholic liver disease than in those with nonalcoholic liver disease. The prevalence of the various lower gastrointestinal lesions in both groups was similar. Of particular interest is the fact that in alcoholic cirrhotics, the prevalence of gastritis, gastric ulcer and duodenal ulcer disease was unrelated to the degree of portal hypertension, whereas in the nonalcoholic cirrhotics the prevalence of gastritis and duodenal ulcer disease but not gastric ulcer disease was associated significantly with the degree of portal hypertension as assessed by the presence or absence of large esophageal varices, ascites, and hepatic encephalopathy.

Congestive gastroenteropathy--an extension of nonvariceal upper gastrointestinal bleeding in portal hypertension

Three cirrhotic patients with acute and chronic gastrointestinal blood loss are described. All had extensive gastric mucosal changes on endoscopy consistent with congestive gastropathy and also had extensive duodenal and jejunal changes consisting of multiple friable punctate areas of erythema. Two patients had esophageal varices from which bleeding could not be documented. The mucosal abnormalities seen in the small intestine of all three patients were similar to those within the stomach and are thought to represent an extension of congestive gastropathy and to be contributing to the blood loss. We propose that the term "congestive gastropathy" be replaced by a more comprehensive term, "congestive gastroenteropathy." The cause of these mucosal abnormalities remains unclear. Attempts at endoscopic therapy of these extensive abnormalities should be avoided until a greater understanding of the underlying pathophysiology is reached.

Gastric mucosa in patients with portal hypertension: prevalence of capillary dilatation and Campylobacter pylori

To determine whether the "congestive" gastropathy associated with portal hypertension showed distinctive histological features independent of inflammatory gastritis, endoscopic biopsy specimens of gastric mucosa from 23 patients with portal hypertension and 25 patients with non-ulcer dyspepsia were examined. Active chronic gastritis associated with Campylobacter pylori was found in three patients with portal hypertension compared with 13 patients with non-ulcer dyspepsia. The changes of reflux gastritis were seen in nine patients with portal hypertension compared with three patients with non-ulcer dyspepsia. Mucosal capillary dilatation, assessed on sections stained for factor VIII related antigen, a specific marker for endothelial cells, was significantly greater in biopsy specimens from patients with portal hypertension but this difference was not apparent on sections stained conventionally. The degree of capillary dilatation was unrelated to the presence of histological gastritis. These observations support the view that portal hypertension is associated with a distinctive gastropathy characterised by prominence and dilatation of mucosal capillaries.

Portal hypertension

Portal hypertension is a frequent syndrome characterized by a chronic increase in portal venous pressure and by the formation of portal-systemic collaterals. Its main consequence is massive bleeding from ruptured esophageal and gastric varices. Bleeding is promoted by increased portal and variceal pressure, and is favored by dilatation of the varices. The evaluation of the portal hypertensive patient should include the assessment of portal vein patency by ultrasonography, endoscopic evaluation of the presence, size, and extent of esophageal varices, and hemodynamic studies with measurements of portal pressure and of portal-collateral blood flow. The preferred techniques are hepatic vein catheterization and measurement of azygos blood flow. Endoscopic measurements of variceal pressure and estimations of portal blood velocity by the Doppler technique have recently been introduced, but are still research procedures. Acute variceal hemorrhage should be treated under intensive care. Specific therapy to arrest variceal bleeding includes balloon tamponade, vasopressin, somatostatin, sclerotherapy, and emergency surgery. Treatment of portal hypertension is aimed at preventing variceal hemorrhage and bleeding-related deaths. Pharmacologic prophylaxis is based on the use of drugs that cause a sustained reduction in portal pressure; most studies have used propranolol. Surgery and endoscopic sclerotherapy can also be used to prevent rebleeding.

The surgeon's role in the management of portal hypertension

Patients with portal hypertension are referred to surgeons for several reasons. These include the management of continued active variceal bleeding; therapy after a variceal bleed to prevent further recurrent bleeds; consideration for prophylactic surgical therapy to prevent the first variceal bleed; or, rarely, an unusual cause of portal hypertension which may require some specific surgical therapy. Injection sclerotherapy is the most widely used treatment for both acute variceal bleeding and long-term management after a variceal bleed. Unfortunately it has probably been overused in the past. The need to identify the failures of sclerotherapy early and to treat them by other forms of major surgery is emphasized. The selective distal splenorenal shunt is the most widely used portosystemic shunt today, particularly in nonalcoholic cirrhotic patients. The standard portacaval shunt is still used for the management of acute variceal bleeding as well as for long-term management, particularly in alcoholic cirrhotic patients. For acute variceal bleeding the surgical alternative to sclerotherapy or shunting is simple staple-gun esophageal transection, whereas in long-term management the main alternative is an extensive devascularization and transection operation. Liver transplantation is the only therapy that cures both the portal hypertension and the underlying liver disease. All patients with cirrhosis and portal hypertension should be assessed as potential liver transplant recipients. If they are candidates for transplantation, sclerotherapy should be used to treat bleeding varices whenever possible, as this will interfere least with a subsequent liver transplant.